University of the VisayasCollege of Nursing

Banilad, Mandaue City 6014

Name: ____________________________________________ Score: ______________________

1. The nurse asks each client preoperatively for the name and dose of all prescription and over-the –counter medications taken before surgery because they:

a. May cause allergies to developb. Are automatically ordered postoperativelyc. Should always be taken the morning of surgery with sips of waterd. May create a greater risks for anesthetic and surgical complications

2. Family members should be included when the nurse teaches the client preoperative exercise so they can:

a. Coach the client postoperativelyb. Demonstrate to the client at homec. Relieve the nurse by getting the client to do exercise every 2 hoursd. Practice with the client while waiting to be taken to the operating room

3. Because an older adult is at increased risk for respiratory complications after surgery, the nurse should:

a. Withhold the pain medications and ambulate the client every 2 hoursb. Monitor fluid and electrolyte status every shift and vital signs with temperature every

4 hoursc. Orient the client to the surrounding environment frequently and ambulate the client

every 2 hoursd. Encourage the client to turn, deep breathe and cough frequently, and ensure adequate

pain control

4. A client with a prothrombin time (PT) or an activated partial thromboplastin time (APTT) greater than normal is at risk postoperatively for:

a. Infectionb. Bleedingc. Low urine outputd. Cardiac dysrhythmias

5. When the client is deep breathing and coughing, it is important to have the client sit because this position:

a. Is more comfortableb. Facilitates expansion of the thorax

c. Helps the client to splint with a pillowd. Increases the client’s view of the room and is more relaxing

6. In the postoperative period you note that the client has a heart rate of 130 beats per minute and a respiratory rate of 32 breaths per minute; you also assess jaw muscle rigidity and rigidity of limbs, abdomen and chest. What do you suspect, and what intervention is indicated?

a. Infection – notify surgeon and anticipate administration of antibioticb. Pneumonia – listen to breath sounds, notify surgeon, and anticipate order for chest

radiographyc. Hypertension – check blood pressure, notify surgeon, and anticipate administration of

antihypertensived. Malignant hyperthermia – notify surgeon/anesthesia provider immediately, prepare to

administer dantrolene sodium, and monitor vital signs frequently

7. When repositioning an immobile client, the nurse notices redness over the bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating:

a. A local skin infection requiring antibioticsb. This client has sensitive skin and requires special bed linensc. A stage III pressure ulcer needing the appropriate dressingd. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured

area

8. This type of pressure ulcer has an observable pressure related alteration of the intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching).

a. Stage I c. Stage IIIb. Stage II d. Stage IV

9. Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to:

a. Allow the area to be exposed to air until all drainage has stoppedb. Place several cold packs over the areas, protecting the skin around the woundc. Cove the areas with sterile saline-soaked towels and immediately notify the surgical

team; this is likely to indicate a wound eviscerationd. Cover the area with sterile gauze, place tight binder over the areas, and ask the client

to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly

10. Serous drainage from a wound is defined as:a. Fresh bleedingb. Thick and yellowc. Clear, watery plasmad. Beige to brown and foul smelling

11. A complication of warm compress is indicated:a. To relieve edemab. For a client who is shiveringc. To improve blood flow to an injured partd. To protect bony prominences from pressure ulcer

12. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child?

a. Tell her not to cry and it will be betterb. Provide opportunity to the client to tell their storyc. Encourage her to accept or to replace the lost persond. Discourage the client in expressing her emotions

13. It is the gradual decrease of the body’s temperature after death.a. Livor mortisb. Rigor mortisc. Algor mortisd. None of the above

14. When providing a continuous enteral feeding, which of the following action is essential for the nurse to do?

a. Place the client on the left side of the bedb. Attach the feeding bag to the current tubingc. Elevate the head of the bedd. Cold the formula before administering it

15. Kussmaul’s breathing is;a. Shallow breaths interrupted by apneab. Prolonged gasping inspiration followed by a very short, usually inefficient expirationc. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.d. Increased rate and depth of respiration

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16.  Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in?

a. Depressionb. Bargainingc. Deniald. Acceptance

17. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:

a. Pulse rate greater than 100 beats per minuteb. Blood pressure of 140/90c. Respiratory rate greater than 20 breaths per minuted. Frequent bowel sounds

18. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The Nurse documents this as:

a. Wheezesb. Rhonchic. Gurglesd. Vesicular

19. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?

a. Use sterile gloves when obtaining urineb. Open the drainage bag and pour out the urinec. Disconnect the catheter from the tubing and get urined. Aspirate urine from the tubing port using a sterile syringe

20. Which of the following is inappropriate nursing action when administering NGT feeding?a. Place the feeding 20 inches above the pint of insertion of NGTb. Introduce the feeding slowlyc. Instill 60ml of water into the NGT after feedingd. Assist the patient in fowler’s position

21. When examining a patient with abdominal pain the nurse in charge should assess:a. Any quadrantb. The symptomatic quadrant firstc. The symptomatic quadrant lastd. The symptomatic quadrant either second or third

22. A female patient with a terminal illness is in denial. Indicators of denial include:

a. Shock dismay

b. Numbness

c. Stoicism

d. Preparatory grief

23. A scrub nurse in the operating room has which responsibility?a. Positioning the patientb. Assisting with gowning and glovingc. Handling surgical instruments to the surgeond. Applying surgical drapes

24. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?a. Leave the medication at the patient’s bedside

b. Tell the patient to be sure to take the medication. And then leave it at the bedside

c. Return shortly to the patient’s room and remain there until the patient takes the medication

d. Wait for the patient to return to bed, and then leave the medication at the bedside

25. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?a. Red blood cell countb. Sputum culturec. Total hemoglobind. Arterial blood gas (ABG) analysis

26. The process of exchanging gases between the cells and the blood is known as:

a. Ventilation b. Perfusionc. Internal Respirationd. B and C

27. What is the correct sequence in conducting an abdominal examination?a. Inspection, percussion, palpation, percussionb. Palpation, inspection, auscultation, percussionc. Inspection, auscultation, percussion, palpationd. Auscultation, percussion, palpation, inspection

28. Before an abdominal assessment, which is least likely implemented?a. The client should void before the procedureb. The client should be placed on a lithotomy position

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c. Warm hands should be used in palpationd. Warm stethoscope should be used in auscultation

29. The physician ordered a low-sodium diet to the client.  Which of the following food will the nurse avoid to give to the client?a. Orange juiceb. Whole milkc. Ginger aled. Black coffee

30. The nurse encourages the client to wear compression stockings.  What is the rationale behind in using compression stockings?a. Compression stockings promote venous returnb. Compression stockings divert blood to major vesselsc. Compression stockings decreases workload on the heartd. Compression stockings improve arterial circulation

31. A nurse is providing a discharge instruction to the client about the self-catheterization at home.  Which of the following instructions would the nurse include?a. Wash the catheter with soap and water after each useb. Lubricate the catheter with Vaselinec. Perform the Valsalva maneuver to promote insertiond. Replace the catheter with a new one every 24 hour

32. During tracheal suctioning, the nurse should implement safety measures.  Which of the following should the nurse implements?a. limit suction pressure to 150-180 mmHgb. suction for 15-20 secondsc. wear eye gogglesd. remove the inner cannula

33. The nurse is to perform tracheal suctioning.  During tracheal suctioning, which nursing action is essential to prevent hypoxemia?a. aucultating the lungs to determine the baseline data to assess the effectiveness of

suctioningb. removing oral and nasal secretionsc. encouraging the patient to deep breathe and cough to facilitate removal of upper-airway

secretionsd. administering 100% oxygen to reduce the effects of airway obstruction during suctioning.

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34. Which of the following is not considered a fat soluble vitamin? a. Vitamin A b. Vitamin B1 c. Vitamin K d. Vitamin E

35. Which of the following is not considered a water soluble vitamin? a. Vitamin B3 b. Vitamin C c. Vitamin D d. Vitamin B12

36. Another name for Vitamin B1 is ____ . a. Thiamine b. Riboflavin c. Pyridoxine d. Cobalamin

37. Which of the following foods is not high in potassium? a. Oranges b. Bananas c. Tomatoes d. Turnips

38. Which of the following vitamins will be the most common in: leafy green vegetables, egg yolk and soy oil? a. Vitamin A b. Vitamin D c. Vitamin E d. Vitamin K

39. Another name for Vitamin B12 is ____ . a. Pantothenic Acid b. Cyanocobalamin c. Niacin d. Riboflavin

40. Which of the following match with the definition: a poor output of urine? a. Oliguriab. Pyuriac. Enuresisd. Diuresis

41. A client is scheduled for NGT Feeding. Checking the residual volume, you determined that he has 40 cc residual from the last feeding. You reinstill the 40 cc of residual volume and added the 250 cc of feeding ordered by the doctor. You then instill 60 cc of water to clear the lumen and the tube. How much will you put in the client’s chart as input?a. 250 ccb. 290 ccc. 350 ccd. 310 cc

42. Which one of the following is NOT a function of the Upper airway?a. For clearance mechanism such as coughingb. Transport gases to the lower airwaysc. Warming, Filtration and Humidification of inspired aird. Protect the lower airway from foreign matter

43. Which of the following if done by a nurse indicates deviation from the standards of NGT feeding?a. Do not give the feeding and notify the doctor of residual of the last feeding is greater than

or equal to 50 mlb. Height of the feeding should be 12 inches about the tube point of insertion to allow slow

introduction of feedingc. Ask the client to position in supine position immediately after feeding to prevent

dumping syndromed. Clamp the NGT before all of the water is instilled to prevent air entry in the stomach

44. You are about to set the suction pressure to be used to Mr. Hamilton. You are using a Wall unit suction machine. How much pressure should you set the valve before suctioning Mr. Hamilton?a. 50-95 mmHgb. 200-350 mmHgc. 100-120 mmHgd. 10-15 mmHg

45. There are four catheter sizes available for use, which one of these should you use for Mr. Hamilton?a. Fr. 18b. Fr. 12c. Fr. 10d. Fr, 5

46. The wall unit is not functioning; you then try to use the portable suction equipment available. How much pressure of suction equipment is needed to prevent trauma to mucus membrane and air ways in case of portable suction units?a. 2-5 mmHgb. 5-10 mmHgc. 10-15 mmHg

d. 15-25 mmHg

47. Among the following foods, which has the highest amount of potassium per area of their meat?a. Cantaloupeb. Avocadoc. Raisind. Banana

48. Which of the following is TRUE about Expiration?a. A passive processb. The length of which is half of the length of Inspirationc. Stridor is commonly heard during expirationd. Requires energy to be carried out

49. All but one of the following is a purpose of steam inhalationa. Mucolyticb. Warm and humidify airc. Administer medicationsd. Promote bronchoconstriction

50. Which of the following is true about nutrition?a. It is the process in which food are broken down, for the body to use in growth and

developmentb. It is a process in which digested proteins, fats, minerals, vitamins and carbohydrates are

transported into the circulationc. It is a chemical process that occurs in the cell that allows for energy production, energy

use, growth and tissue repaird. It is the study of nutrients and the process in which they are use by the body

51. Refers to the extra air that can be inhaled beyond the normal tidal volumea. Inspiratory reserve volumeb. Expiratory reserve volumec. Functional residual capacityd. Residual volume

52. This is the amount of air remained in the lungs after a forceful expirationa. Inspiratory reserve volumeb. Expiratory reserve volumec. Functional residual capacityd. Residual volume

53. Which of the following is not true about the Large Intestine?a. It absorbs around 1 L of water making the feces around 75% water and 25% solidb. The stool formed in the transverse colon is not yet well formedc. It is a sterile body cavity

d. It is called large intestine because it is longer than the small intestine

54. Which of the following is TRUE in postural drainage?a. Patient assumes position for 10 to 15 minutesb. Should last only for 60 minutesc. Done best P.Cd. An independent nursing action

55. Which of the following is the BEST method in assessing for the correct placement of the NGT?a. X-Rayb. Immerse tip of the tube in water to check for bubbles producedc. Aspirating gastric content to check if the content is acidicd. Instilling air in the NGT and listening for a gurgling sound at the epigastric area

56. When should a nurse suction a client?a. As desiredb. As neededc. Every 1 hourd. Every 4 hours

57. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM?a. Nasal Cannulab. Simple Face maskc. Non Rebreather maskd. Partial Rebreather mask

58. Which is not a clear liquid diet?a. Hard candyb. Gelatinc. Coffee with Coffee mated. Bouillon

59. Which of the following is the initial sign of hypoxemia in an adult client?1. Tachypnea2. Tachycardia3. Cyanosis4. Pallor5. Irritability6. Flaring of Nares

a. 1,2b. 2,5c. 2,6d. 3,4

60. Which of the following is included in a full liquid diet?a. Popsiclesb. Pureed vegetable meatc. Pineapple juice with pulpsd. Mashed potato

61. Central venous access devices are beneficial in pediatric therapy because:a.    They don’t frighten children.b.    Use of the arms is not restricted.c.    They cannot be dislodged.d.    They are difficult to see.

62. A male patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. He knows it can be inserted without going to the operating room. He mentions that, “at least the doctor won’t be wearing surgical garb, will he?” How will the nurse answer the patient?a.    “You are correct. It is a minor procedure performed on the unit and does not necessitate

surgical attire.” b.    “To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gown and gloves.” c.    “It depends on the doctor’s preference.” d.    “Most doctors only wear sterile gloves, not a cap, mask, or sterile gown.”

63. A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply?a.    “You will have general anesthesia so you won’t feel anything.”b.    “It will be inserted rapidly, and any discomfort is fleeting.”c.    “The insertion site will be anesthetized. Threading the catheter through the vein is not painful.”d.    “You will receive sedation prior to the procedure.”

64.   What is the purpose of “tunneling” (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling:a.    Increases the patient’s comfort level.b.    Decreases the risk of infection.c.    Prevents the patient’s clothes from having contact with the catheterd.    Makes the catheter less visible to other people.

65. The primary complication of a central venous access device (CVAD) is:a.    Thrombus formation in the vein.b.    Pain and discomfort.c.    Infection.d.    Occlusion of the catheter as the result of an intra-lumen clot.

66. A 2 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?a.    Use aseptic technique during dressing changesb.    Maintain central line catheter integrityc.    Monitor serum glucose levelsd.    Check results of liver function tests

67. Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention?a.    Temperature of 37.5 degrees Celsiusb.    Urine output of 300 cc in 4 hoursc.    Poor skin turgord.    Blood glucose of 350 mg/dl

68. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?a.    Record the number of stools per dayb.    Maintain strict intake and output recordsc.    Sterile technique for dressing change at IV sited.    Monitor for cardiac arrhythmias

Situation – One of the realities that we are confronted with is our mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.

69. Irma is terminally ill, she speaks to you in confidence. You now feel that Irma’s family could be helpful if they knew what Irma has told to you. What should you do first?a) Tell the physician who in turn could tell the familyb) Obtain Irma’s permission to share the information in the familyc) Tell Irma that she has to tell her family what she told youd) Make an appointment to discuss the situation with the family

70. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help her by:a. Coming back periodically and indicating your availability if she would like you to sit

with herb. Insisting that Ruby should talk with you because it is not good to keep everything insidec. Leaving her alone because she is uncooperative and unpleasant to be withd. Encouraging her to be physically active as possible

71. Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves, is depressed. Which of the following would best help him during his depression?a. Arrange for visitors who might cheer himb. Sit down and talk with him for a while

c. Encourage him to look at the brighter side of thingsd. Sit silently with him

72. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his impending death?a. “I’m ready to go.”b. “I have resigned myself to dying.”c. “What’s the use?”d. “I’m giving up”

73. Marla, 90 years old has planned ahead for her death-philosophically, socially, financially and emotionally. This is recognized as:a) Acceptance that death is inevitableb) Avoidance of the true situationc) Denial with planning for continued lifed) Awareness that death will soon occur

Situation – Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.

74. Andrea loses consciousness. You should prepare for which of the following FIRST?a. Placement of nasogastric tubeb. Placement of a second IV linec. Endotracheal intubation or surgical airway placementd. CT scan of head

75. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:

a. Biot’sb. Kussmaul’sc. Cheyne Stokesd. Eupnea

76. You know the apnea is seen in client’s with cheyne stoke respiration, APNEA is defined as:a. Inability to breath in a supine position so the patient sits up in bed to breathe.b. The patient is dead, the breathing stopsc. There is an absence of breathing for a period of time usually 15 seconds or mored. A period of hypercapnea and hypoxia due to cessation of respiratory effort inspite of

normal respiratory functioning

77. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication related to TPN? a. weighing the client daily b. Monitoring I&O c. Monitoring the temperature

d. Monitoring the serum blood urea nitrogen (BUN)

78. A female client tells the home health nurse that she has not had a stool since coming home from the hospital after surgery 4 days ago. Which of the following is the most appropriate diet for this client at this time?

a. High-fiber dietb. Full-liquid diet c. Low-residue diet d. Low-sodium diet

79. A physician has ordered a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the food tray to be sure that which of the following is true?

a. Sodiums foods are restricted b. All food item are lukewarm in temperature c. All food items are liquid at body temperature d. At least one serving of low-fat milk is served.

80. A nurse is developing a plan of care for a client with a nasogastric (NG) tube feeding in place. When formulating the plan of care, the nurse keeps which of the following in mind?

a. Aspiration is a concern with a nasogastric tube feeding. b. The client needs to be maintained in supine position. c. The NG tube needs to be changed with every other feeding. d. The rate of the feeding needs to be increased if the infusion rate falls behind schedule.

81. A nurse is preparing a plan of care for a client receiving enteral feedings via a gastrotomy tube (G-tube). The nurse plans to include which of the following interventions in the plan of care?

a. To provide oral fluids three times per day b. To check around the stoma site for skin irritation. c. To medicate with antidiarrheal medications everyday. d. To use sterile technique when administering the tube feedings.

82. A nurse is caring for a client with a diagnosis of dehydration. The client is receiving intravenous fluids. which of the following assessment data would indicate to the nurse that the dehydration is not resolved?

a. A urine specific gravity of 1.033 b. A urine output that is pale yellow in color. c. A blood pressure of 120/80 mmHg d. An oral temperature of 98.8 F

83. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administer an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the nurse observed the LPN perform which of the following?

a. Changing the needle after drawing up the dose and before injection. b. Preparing an air lock when drawing up the medication c. Using a Z-tract method for injection. d. Massaging the injection site well after injection.

84. A registered nurse (RN) has instructed a nursing assistant (NA) to administer soap solution enemas until clear to a client scheduled for a colonoscopy. The NA tells the nurse that three enemas have been administered and that the client is still passing brown liquid stool. Which of the following instructions would the RN give to the NA?

a. Wait 30 minutes abd then administer another enema b. Administer a Fleet enemac. Administer an oil-retention enemad. Stop administering the enemas until the physician is notified.

85. Which of the following is not considered a right of medication? a. Doseb. Timec. Routed. Limit

86. A routine urinalysis is ordered for Mr. Pineda. If the specimen cannot be sent immediately to the laboratory, the nurse should: a. Take no special action b. Refrigerate the specimen c. Store on dry side of utility roomd. Discard and collect a new specimen later

87. When Mr. Pineda, who has urinary retention catheter in place, complaints of discomfort in the bladder and urethra the nurse should first: a. Notify the physicianb. Milk the tubing gentlyc. Check the patency of the catheter d. Irrigate the catheter with prescribed solutions

88. A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be: a. Call the physicianb. Slow the flow ratec. Stop the blood immediatelyd. Relieved the symptoms with an ordered antihistamines

Situation: (Questions 90 – 92). Mr. Villa was admitted to the respiratory floor with COPD. The nurse finds him extremely restless, incoherent, and showing signs of acute respiratory distress. He is using accessory muscles for breathing and is diaphoretic and cyanotic89. The best initial action by the nurse is to:

a. Administered oxygen as ordered b. Assess vital signs and neural vital signs c. Administered medication which has been ordered for pain d. Call respiratory therapy for a prescribed ABG (arterial -blood gas) analysis

90. An order is written for oxygen by nasal cannula at 2 liters per minute. Which assessment is most useful in assessing the adequacy of the oxygen therapy? a. Respiratory rate b. Color of mucus membranes c. Pulmonary function tests d. Arterial blood gases

91. Mr. Villa needs frequent monitoring of arterial blood gases. Following the drawing of arterial blood gasses it is essential for the nurse to do which of the following? a. Encourage the client to cough an deep breath b. Apply pressure to the puncture site for 5 minutes c. Shake the vial of blood before transporting it to the lab d. Keep the client on bed rest for 2 hours

92. When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?a. The client sets the drainage bag on the floor while sitting down.b. The client keeps the drainage bag below the bladder at all times.c. The client clamps the catheter drainage tubing while visiting with the family.d. The client loops the drainage tubing below its point of entry into the drainage bag

93. Nurse Agnes is reviewing the report of a client’s routine urinalysis. Which value should the nurse consider abnormal?a. Specific gravity of 1.03b. Urine pH of 3.0c. Absence of proteind. Absence of glucose

94.   A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the nurse is aware that the functions of the three lumens include:a. Continuous inflow and outflow of irrigation solution.b. Intermittent inflow and continuous outflow of irrigation solution.c. Continuous inflow and intermittent outflow of irrigation solution.d. Intermittent flow of irrigation solution and prevention of hemorrhage.

95.   Nurse Claudine is reviewing a client’s fluid intake and output record. Fluid intake and urine output should relate in which way?a. Fluid intake should be double the urine output.b. Fluid intake should be approximately equal to the urine output.c.  Fluid intake should be half the urine output.d.    Fluid intake should be inversely proportional to the urine output.

96. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take?a.    Hold the feedingb.    Reinstill the amount and continue with administering the feedingc.    Elevate the client’s head at least 45 degrees and administer the feedingd.    Discard the residual amount and proceed with administering the feeding

97. A nurse is inserting a nasogastrictube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action?a.    Quickly insert the tubeb.    Notify the physician immediatelyc.    Remove the tube and reinsert when the respiratory distress subsidesd.    Pull back on the tube and wait until the respiratory distress subsides

98. A nurse is preparing to remove a nasogartric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube?a.    Exhaleb.    Inhale and exhale quicklyc.    Take and hold a deep breathd.    Perform a Valsalva maneuver

99. Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would:a.    Position the client supine to assist in medication absorptionb.    Aspirate the nasogastric tube after medication administration to maintain patencyc.    Clamp the nasogastric tube for 30 minutes following administration of the medicationd.    Change the suction setting to low intermittent suction for 30 minutes after medication  administration

100. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test?a.    Fast for 8 hours before the testb.    Eat a regular supper and breakfastc.    Continue to take all oral medications as scheduledd.    Monitor own bowel movement pattern for constipation

101. The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next?a.    Palpates the abdomen for size

b.    Palpates the liver at the right rib marginc.    Listens to bowel sounds in all for quadrantsd.    Percusses the right lower abdominal quadrant