Professional Documents
Culture Documents
Funda Test Drill
Funda Test Drill
The position that is indicated for Rosanna, age 23, after surgery for a perforated appendix with localized peritonitis
is the:
a. Semi-Fowler's position
c. Sims' position
d. Trendelenburg position
Question 2
The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the
following should the nurse record as objective data?
Question 3
Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. A nurse is
monitoring Helen for Disseminated Intravascular Coagulopathy. Which assessment finding is least likely to be
associated with DIC?
Question 4
What is the problem with the following outcome goal, “Patient will state pain is less than or equal to 3 on a 0 to 10
pain scale”?
Question 5
A nurse is performing oropharyngeal suctioning on an unconscious patient. Which of the following actions is safe?
a. Allow 20- to 30-second intervals between each suction, and limit suctioning to a total of 15 minutes
d. Apply suction for 5 seconds while inserting the catheter and continue for another 5 seconds before withdrawing
Question 6
Princess, age 30, requires a blood transfusion. Her blood type is AB. To prevent complications of blood
incompatibilities, Nurse Yuri knows that this patient may receive:
Question 7
The patient states, “My chest hurts and my left arm feels numb.” What is the type and source of this data?
Question 8
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedures is:
a. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion
loose on the exhalation cycle
b. Percussion uses only one hand while vibration uses both hands
c. Percussion slaps the chest to loosen secretions while vibration shakes the secretions with inhalation of air
Question 9
When her membranes rupture, the nurse's first action should be to:
Question 10
Anne has received treatment for a warm, reddened, painful area in the breast as well as cracked and fissured
nipples. The client expresses the desire to continue breastfeeding. The following are instructions that the nurse
should include to prevent recurrence of this condition EXCEPT:
Question 11
Which of the following patients meet the criteria for selection of the apical site for assessment of the pulse rather
than a radial pulse?
d. A patient is in shock
Question 12
Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. Based on
these findings, the nurse would prepare the client for:
c. The need for weekly monitoring of coagulation studies until the time of delivery
Question 13
Correct
Question text
The theorist who is the proponent of the Self Care Deficit theory of nursing is:
a. Betty Neuman
b. Dorothea Orem
Question 14
A patient's blood gases reflect diabetic acidosis. Nurse Charitie should expect:
a. Decreased PO2
b. Decreased HCO3
c. Increased PCO2
d. Increased pH
Question 15
Tibo, age 27, has a chest tube to a Pleur-evac® drainage system attached to wall suction. An order to ambulate the
patient has been received. To ambulate the patient safely, Nurse Bro should:
b. Disconnect the Pleur-evac® from the patient's chest tube, leave it attached to the bed, ambulate the patient,
and then reconnect the chest tube when he is returned to bed
c. Clamp the chest tube and carefully ambulate the patient a short distance
d. Carefully ambulate the patient, keeping the Pleur-evac® lower than the patient's chest
Question 16:
During the third stage of labor, the nurse may have which of the following responsibilities?
a. Push down on the relaxed uterus to aid in the removal of the placenta
b. Note if the placenta makes a Schultz presentation, which is a sign of gross complication
Question 17
The theorist that describes nursing as a significant, therapeutic, interpersonal process, which functions
cooperatively with other human processes that make health possible for individuals in communities is:
a. Hildegard Peplau
b. Joyce Travelbee
c. Patricia Benner
Question 18
Anne is visited by the home health nurse two weeks after delivery. The woman is febrile with flu-like symptoms.
On assessment, the nurse notes a warm, reddened painful area of the right breast. The best initial action of the
nurse is to:
Question 19
Nurse John is completing the exchange by draining the dialysate and notices the dialysate is opaque. The nurse
best interprets this finding as:
b. A sign of infection
Question 20
Cath, 21 years old, has difficulty of breathing when on her back and must sit upright in bed in order to breathe
effectively and comfortably. The nurse documents this condition as:
a. Tachypnea
b. Dyspnea
c. Apnea
d. Orthopnea
Question 21
Situation 2. John has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at
risk for infection because of retained secretions. Part of Nurse Mara’s nursing care plan is to loosen and remove
excessive secretions in the airway. Nurse Mara listens to John’s bilateral sounds and finds that congestion is in the
upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segment of the lungs
when the nurse does percussion would be:
b. Patient lying on his back then flat on his abdomen on Trendelenburg position
c. Patient lying flat in his back and then flat on his abdomen
d. Patient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on
his abdomen
Question 22
Which of these patients has a problem with transport of oxygen from the lungs to the tissues?
Question 23
An adult client with a history of diabetes is scheduled for a transmetatarsal amputation. When should the client's
discharge planning begin?
Question 24
Mr. Beans, a 37-year-old client with a nasogastric tube connected to a low continuous suction for abdominal
decompression. Nurse Junelyn notes that gastric fluid in the suction tubing is not moving and the patient's
abdomen is becoming distended. The nurse's best action is to:
Question 25
The physician is going to order a hypotonic intravenous solution for a patient with cellular dehydration. Nurse
Vince would expect which of the following fluids to be administered?
a. Lactated Ringer's
Question 26
Correct
c. Fever
d. Exercise
Question 27
Incorrect
When discussing the regaining of bowel control with Mr. Shananga who has had surgery for a colostomy, which is
most important?
b. High-protein diet
c. Irrigation routine
Question 28
Correct
Which nursing intervention is appropriate for Nurse Yuri to take when setting up supplies for Toni, age 45, who
requires a blood transfusion?
a. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
b. Prime tubing of blood administration set with normal saline solution, completely filling filter
c. Add any needed IV medication in the blood bag within one half hour of planned infusion
d. Use a small-bore catheter to prevent rapid infusion of blood products that may lead to a reaction
Question 29
Incorrect
The laboratory tests that would indicate that the liver of a patient with cirrhosis is compromised and neomycin
enemas might be helpful would be:
a. Ammonia level
Question 30
In the emergency room, Nurse Jhang is assigned to attend to the patient with lacerations on the arms. While
assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most
immediate nursing action would be to:
Question 31
The rationale for giving medications through the subcutaneous route is:
Question 32
When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
Question 33
Situation3: Anne delivered a child two days ago. She is breastfeeding her child. To show Anne how to help her have
good attachment of the infant during breast feeding. Which of the following statements should NOT be included?
c. move the infant quickly onto her breast, aiming the infant's lips well below the nipple
Question 34
Incorrect
Nurse Junelyn is caring for Mr. Turnips who has a nasogastric tube attached to low wall suction. The suction is not
working. Which is the nurse least likely to note when assessing the patient?
c. Patient vomits
Question 35
When preparing an IV piggyback medication for a patient, Nurse Vince is aware that it is essential to:
Question 36
Nurse Jhang applies pressure dressing on the bleeding site. This intervention is done to:
a. Allow the pus to surface faster
d. Promote homeostasis
Question 37
Nurse Archipela is changing the central line dressing of Ms. Go who is receiving total parenteral nutrition (TPN).
The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following?
Question 38
While doing nasopharyngeal suctioning on Hermes, the nurse can avoid trauma to the area by:
c. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
Question 39
Johan, a 29-year-old client who has had thoracic surgery, is admitted to the postanesthesia care unit. After the
chest catheters are attached to a closed drainage system, Nurse Bro should:
a. Check that the fluid in the water seal compartment rises with expiration
b. Ensure that there is vigorous bubbling in the wet suction control compartment
c. Empty the drainage container, measure and record the amount, and send a sample for analysis every 24 hours
d. Ensure the security of the connections from the patient to the drainage unit
Question 40
Kathy, a 30-year-old client with a spontaneous pneumothorax, has had a chest tube for 3 days. On morning
rounds, the physician clamped the chest tube to determine the patient's readiness to have the chest tube
discontinued. Two hours after having the chest tube clamped, the patient began to have difficulty breathing. What
action should Nurse Bro take first?
Question 41
Question 42
Incorrect
The most important test used to determine whether a transplanted kidney is working is:
a.Twenty-four-hour output
c. Renal ultrasound
Question 43
Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. Helen is given
a unit of blood. The realizes that this is necessary, since the bleeding following severe abruptio placenta is usually
caused by:
a. Polycythemia
b. Hypofibrinogenemia
c. Thrombocytopenia
d. Hyperglobulinemia
Question 44
Incorrect
Nurse Charitie is interpreting the results of a blood gas analysis performed on an adult patient. The values include
pH of 7.35, PCO2 of 60, HCO3 of 35, and O2 of 60. Which interpretation is most accurate?
a. The patient is in metabolic acidosis
Question 45
Nurse Junelyn is to irrigate a nasogastric tube every two hours. Which solution should the nurse select to irrigate
the tube?
a. Normal saline
b. Ringer's lactate
c. Tap water
d. Half-strength peroxide
Question 46
When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age. This is an
example of which of the following?
d. Clustering data
Question 47
You will do nasopharyngeal suctioning on Hermes, 30 years old. Your guide for the insertion of the tubing for an
adult would be:
c. The distance form the tip of the nose to the middle of the cheek
Question 48
Mr. Floremonte is obese. When administering subcutaneous injection to an obese patient, it is best for Nurse Flo
to:
c. Spread the skin or pinch at the injection site and inject needle at a 45-90 degree angle
d. Inject needle at a 15 degree angle over the stretched skin of the patient
Question 49
Which of the following instructions can the nurse give to lactating mother?
Question 50
You noted from the lab exams in the chart of Tado, a 25-year-old patient, that he has reduced oxygen in the blood.
This condition is called:
a. Hypoxemia
b. Anemia
c. Cyanosis
d. Hypoxia
Question 51
Question 52
Incorrect
Rosemary, age 20, is to have gastric gavage. When the gavage tube is being inserted, Nurse Claudine should place
the patient in the:
a. High-Fowler's position
b. Mid-Fowler's position
c. Supine position
d. Trendelenburg position
Question 53
A patient with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the
endotracheal tube, the nurse should:
Question 54
Question 55
An adhesive-backed ostomy opening should be how much larger than the stoma?
a. 1/3 inch
b. ¼ inch
c. ½ inch
d. 1/8 inch
Q 56:
The theorist whose theory can be defined as the development of a science of humankind, incorporating the
concepts of energy fields, openness, pattern and organization is:
a. Myra Levine
b. Martha Rogers
c. Dorothy Johnson
d. Imogene King
Question 57
Mr. Billiards has an arteriovenous fistula. Which finding is expected when assessing the fistula?
a. Pulselessness
b. Redness
c. Ecchymotic area
d. Enlarged veins
Question 58
Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. The nurse
realizes that the abdominal pain associated with abruption placenta is caused by:
a. Inflammatory reactions
b. Hemorrhagic shock
c. Concealed hemorrhage
Question 59
The physician orders 3 units of whole blood for Mr. Otol, age 51, who is in hypovolemic shock after a
gastrointestinal hemorrhage. When administering blood, Nurse Yuri first verifies the type and cross-match and
then routinely:
c. Draws blood samples from the patient before and after each unit is transfused
d. Runs the blood at a slower rate during the first 10 to 15 minutes of the transfusion
Question 60
After surgery on the neck, Rosita, age 22, should be placed in a high-Fowler's position to:
Question 61
Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with preeclampsia, moderate vaginal bleeding,
and sudden abdominal pain. The results of the ultrasound indicate that abruptio placenta is present. On Helen’s
admission to the unit the nurse should observe for:
Question 62
Mr. Borat, a 45-year-old male patient, has an order for a nasogastric tube. Before inserting the tube, Nurse Junelyn
measures the amount of tube needed. To determine the amount of tube needed, the nurse should:
a. Measure from the tip of the patient's nose to his earlobe and from the earlobe to the xiphoid process
b. Measure from the chin to the back of the throat and from the back of the throat to the umbilicus
c. Measure from the mouth to the xiphoid process and add 2 inches
d. Measure from the forehead to the ear and from the ear to the umbilicus
Question 63
A community health nurse has scheduled a hypertension clinic in a local shopping mall in which shoppers have the
opportunity to have their blood pressure measured and learn about hypertension. This nursing activity would be
an example of which type of prevention activity?
a. Secondary prevention
b. Primary prevention
c. Tertiary prevention
d. Disease prevention
Question 64
Incorrect
Nurse Edu is administering tracheostomy care to Mr. Posible. Which of the following should be included in the
procedure?
Question 65
The theorist whose major theme is the idea of transcultural nursing and caring is:
a. Virginia Henderson
b. Madeleine Leininger
c. Jean Watson
d. Ernestine Wiedenbach
Question 66
Incorrect
Nurse Mara prepares John for postural drainage and percussion. Which of the following is a special consideration
when doing the procedure?
Question 67
When suctioning Mr. Posible, with a tracheostomy, Nurse Edu must remember to:
Question 68
Correct
Question text
Situation 4: Rita, 27 years old, is a gravida 1 in the active phase of labor. Fetal position is LOA, and cervix is 4 cm
dilated. Rita wants to walk about in the labor room. Which of the following criteria will help the nurse determine
whether she should walk?
b. Frequency of contraction
c. Fetal station
d. Fetal position
Question 69
Nurse Loren is monitoring Mr. Billiards who is undergoing hemodialysis. The patient suddenly becomes cyanotic
and complains of dyspnea and chest pain. His blood pressure is 70/40 mm Hg and his pulse is weak and rapid. The
nurse calls the physician immediately because the signs and symptoms suggest which of the following
complications of dialysis?
a. Air embolism
b. Internal bleeding
d. Disequilibrium syndrome
Question 70
During a colostomy irrigation, if Mr. Shananga complains of abdominal cramps, Nurse Mar Kit should:
Question 71
Incorrect
Nurse John suspects a complication in Mr. Ivler who is receiving peritoneal dialysis. Which of the following
observations would support this evaluation?
c. Cloudy effluent
d. Occasional diarrhea
Question 72
Mr. Shananga is concerned about the odor of the stool in the ostomy drainage bag. Nurse Mar Kit teaches the
patient to include which of the following foods in the diet to reduce odor?
a. Eggs
b. Broccoli
c. Yogurt
d. Cucumbers
Question 73
b. Anton who has chest injury, is pale and with difficulty of breathing
Question 74
Question 75
For a patient with a previous blood pressure of 140/80 and pulse of 64, approximately how long should the nurse
take to release the blood pressure cuff in order to obtain an accurate reading?
a. 30 to 45 seconds
b. 1 to 1.5 minutes
c. 3 to 3.5 minutes
d. 10 to 20 seconds
Question 76
IV orders for a 75-year-old patient include D5 ½ NS with 20 mEq KCl at 75 cc/hr. At 6:00 A.M. a new bag of 1000 ml
was hung. At 8:00 A.M. Nurse Vince sees that only 200 ml remains. The first action by the nurse would be to:
c. Check the site for infiltration and elevate the extremity if needed
d. Slow the IV to “keep open” and check the patient for lung crackles
Question 77
The nurse following the physicians order for client with placenta previa, begins administering oxygen by mask. The
client’s apprehension is increasing and she asked the nurse what is happening. The nurse tells her not to worry,
that she is going to be all right and everything is under control. The nurse statements are:
b. Proper, since the client’s anxieties would be increased if she knew the dangers
c. Questionable, since the client has the right to know what treatment is being given and why
d. Correct, since only the physician should explain why treatment are being done
Question 78
Incorrect
Nurse Yuri is preparing to administer two units of packed red blood cells to Bianca, age 34. The nurse should:
a. Use a special blood filter and an 18-gauge needle to administer the packed red blood cells
b. Administer the prescribed intravenous drugs through the blood administration tubing to ensure proper
distribution throughout the body
d. Understand that blood transfusion reactions usually do not occur until the client has received 500 ml of the
packed red blood cells
Question 79
The physician inserts a chest tube to Mariel, a 24-year-old patient who has been stabbed in the chest, and attaches
it to a closed-drainage system. When caring for the patient, Nurse Bro should:
Question 80
When Rosenda, age 21, is in the right side-lying position after the insertion of a left hip prosthesis, Nurse Claudine
ensures that the patient has an abduction pillow placed between the thighs and that the entire length of the upper
leg is supported. The most important reason for this is to prevent:
Q 81:
When assessing Mr. Peas, a postoperative patient, Nurse Junelyn notes a nasogastric tube to low constant suction,
the absence of a bowel movement since surgery, and no bowel sounds. The most appropriate plan of care based
on these findings is to:
c. Increase the patient's mobility and ensure he is receiving adequate pain relief
d. Discontinue the nasogastric tube as the patient does not need it any more
Question 82
When planning comfort measures to help Rita in active labor to tolerate her pain, the nurse must consider which
of the following?
a. The acceleration phase of labor can be a time of true discomfort and high anxiety
b. Pain medication given during the latent phase of labor is not likely to impair contractions
c. If women are properly prepared, they will require no pain medication to manage their pain
d. Early labor contractions are usually regular, coordinated, and very painful
Question 83
Question 84
A recent nursing graduate has been surprised at the sharp contrast between some clients' lifestyles in their homes
and the nurse's own practices and beliefs. To work therapeutically with the client, what must the nurse do?
Question 85
Incorrect
The patient's arterial blood gases on room air are: pH of 7.33; PO2 of 77; PCO2 of 50; and HCO3 of 23. Nurse
Charitie instructs the patient to:
Question 86
Mr. Posible had a cuffed tracheostomy tube placed 4 weeks ago. The patient is going to begin eating by mouth,
with the tracheostomy tube in place. To prevent aspiration, Nurse Edu will:1. Raise the head of the bed to high-
Fowler's position2. Deflate the cuff on the tracheostomy tube3. Suction the client before eating4. Assess gag and
swallow ability5. Replace the tracheostomy tie
a. All except 5
b. All except 3
c. All except 2
Question 87
If a vaginal examination is to be performed on a client with placenta previa, the nurse should be prepared for an
immediate:
a. Induction of labor
b. Cesarean delivery
c. X-ray examination
d. Forceps delivery
Question 88
Ms. Go is being weaned from total parenteral nutrition (TPN) and is expected to being taking solid food today. The
ongoing solution rate has been 100 ml/hr. Nurse Archipela anticipates that which of the following orders regarding
the TPN solution will accompany the diet order?
Question 89
Incorrect
Mariel, 50 years old, is receiving 5% dextrose in 0.45% saline. The physician has ordered the patient receive one
unit of packed red blood cells. Prior to hanging the blood, Nurse Yuri will prime the blood tubing with which of the
following solutions?
b. 3% saline solution
d. Lactated Ringer's
Question 90
_SITUATION 15.__ NURSE JHANG WITNESSES A VEHICULAR ACCIDENT NEAR THE HOSPITAL WHERE SHE WORKS.
SHE DECIDES TO GET INVOLVED AND HELP THE VICTIMS OF THE ACCIDENT._Her priority nursing action would be
to:
Question 91
Nurse Charitie understands that metabolic acidosis develops in kidney failure as a result of:
a. Impaired glomerular filtration causing retention of sodium and metabolic waste products
b. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood
d. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
Question 92
Mr. Posible's tracheostomy is producing a small amount of thin, white secretions. The stoma is pink with no
drainage noted. Nurse Edu should expect to provide tracheostomy care for the patient every:
a. Four hours
b. Eight hours
c. Hour
d. 24 hours
Question 93
An emergency tracheostomy is performed on a child with croup, and the child is receiving humidified air via a
tracheostomy collar. When caring for this child, the nurse should suction the tracheostomy if the child:
Question 94
Nurse Archipela knows that the primary reason for using a central line is that:
Question 95
Question 96
Mr. Posible had a cuffed tracheostomy tube placed 4 weeks ago. The patient is going to begin eating by mouth,
with the tracheostomy tube in place. To prevent aspiration, Nurse Edu will:1. Raise the head of the bed to high-
Fowler's position2. Deflate the cuff on the tracheostomy tube3. Suction the client before eating4. Assess gag and
swallow ability5. Replace the tracheostomy tie
b. All except 2
c. All except 5
d. All except 3
Question 97
Nurse Archipela is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The nurse asks
Ms. Go to do which of the following most essential action during the tubing changes?
d. Breathe normally
Question 98
A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain.
Which of the following would immediately alert the nurse that the patient has gastrointestinal tract bleeding?
a. Guaiac test
c. Abdominal girth
d. Vital signs
Question 99
When documenting the outcome of Johns treatment Nurse Mara should include the following in her recording,
except:
a. Amount of fluid intake of the patient before and after the procedure
c. Character of breath sounds and respiratory rate before and after procedure
Question 100
Which of the following signs of good attachment should the nurse teach a lactating mother?
a. The chin should touch the breast, the mouth is wide open while the lower lip turned outward, and more areola
visible above than below
b. The chin should touch the breast, the mouth is wide open while the lower lip is turned inward, and more areola
is visible above than below
c. The chin should touch the breast, the mouth is wide open while the lower lip turned outward, and more areola
visible below than above
d. The chin should touch the breast, the mouth is wide open while the lower lip turned inward, and more areola is
visible below than above
Question 101
The nursing instructor is preparing a group of students for their home care rotation. Which of the following groups
are the students most likely to care for?
a. Elderly clients
Question 102
When assessing John for chest percussion or chest vibration and postural drainage, Nurse Mara would focus on the
following, except:
a. Doctor’s order regarding position restrictions and the patient’s tolerance for lying flat
Question 103
Incorrect
The physician orders oropharyngeal suctioning as needed for a patient in a coma. The nurse prepares to suction
when assessment reveals:
Question 104
Incorrect
Ms. Go with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter.
Nurse Archipela assesses the client and suspects an air embolism. The nurse should immediately place the patient
in which of the following positions?
a. On the right side with the head higher than the feet
b. On the left side with the head higher than the feet
c. On the left side with the head lower than the feet
d. On the right side with the head lower than the feet
Question 105
After a total hip replacement surgery, Nurse Claudine should avoid placing Rosario, age 25, in the:
a. Semi-Fowler's position
b. Orthopneic position
c. Supine position
d. Lateral position
Question 106
Before scheduling a patient for endoscopic retrograde cholangiopancreatography (ERCP), the nurse should assess
the patient's:
a. Serum glucose
b. Bilirubin level
c. Blood pressure
d. Urine output
Question 107
Which of the following demonstrates that the nurse is participating critical thinking?
a. The nurse finds a quick and logical answer, even to complex questions
b. The nurse makes her point with clever and persuasive remarks to win an argument
c. The nurse admits she does not know how to do a procedure and requests help
d. The nurse accepts without question the values acquired in nursing school
Question 108
When caring for Mr. Ivler who is receiving peritoneal dialysis, Nurse John should:
a. Position the patient from side to side if fluid is not draining adequately
b. Remove the cannula at the end of the procedure and apply a dry, sterile dressing
c. Maintain the patient in a flat, supine position during the entire procedure
Question 109
Paul Jake, age 25, arrives in the post-anesthesia care unit after a segmental resection of the right lower lobe of the
lung, with a chest tube drainage system in place. Nurse Bro caring for the client should:
b. Secure the chest catheter to the wound dressing with a sterile safety pin
d. Mark the time and the fluid level on the side of the drainage chamber
Question 110
Correct
When assessing Mr. Ivler during peritoneal dialysis, Nurse John observes that drainage of the dialysate from the
peritoneal cavity has ceased before the required amount has drained out. The nurse should assist the patient to:
c. Drink 8 oz of water
Question 111
Correct
The community health nurse is preparing to conduct a home visit. When performing the home visit, how should
the nurse best implement the principles of infection control?
a. Remove the client's soiled wound dressings from the home promptly
c. Perform hand hygiene before and after giving direct client care
Question 112
Correct
Mr. Billiards is placed on hemodialysis three times a week. Which is an attainable short-term goal for this patient
when he is placed on hemodialysis?
Question 113
Incorrect
When caring for Mr. Billiards who has had an arteriovenous shunt inserted for hemodialysis, Nurse Loren should:
c. Take the blood pressure every 4 hours, using the arm that contains the shunt
Question 114
Mr. Shananga tells Nurse Mar Kit that his wife does not let him change his colostomy bag himself. Which response
by the nurse indicates an understanding of the situation?
Question 115
Incorrect
Potassium chloride is to be added to an infant's intravenous fluids. Before adding this electrolyte, Nurse Vince
should determine that:
Question 116
a. Dyspnea
d. Precordial pain
Question 117
A nurse is suctioning fluids from a patient via a tracheostomy tube. When suctioning, the nurse must limit the
suctioning to a maximum of:
a. 30 seconds
b. 5 seconds
c. 1 minute
d. 10 seconds
Question 118
After the treatment, the patient is sent home and asked to come back for follow-up care. Your responsibilities
when the patient is to be discharged include the following, except:
c. Encouraging the patient to go to the out patient clinic for follow up care
d. Instructing the patient to see you after discharge for further assistance
Question 119
Correct
The best blood test for the nurse to use to evaluate fluid loss resulting from burns is the:
b. Blood pH
c. Sedimentation rate
d. Hematocrit
Question 120
Incorrect
An adult woman is admitted with metabolic acidosis. Which set of arterial blood gases should Nurse Charitie
expect to find in a client with metabolic acidosis?
Question 121
Correct
The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
a. Pedal
b. Apical
c. Radial
d. Femoral
Question 122
b. Reduce anaphylaxis
c. Relieve hypersensitivity to allergen
Question 123
Incorrect
When preparing the epinephrine injection from an ampule, Nurse Flo initially:
a. Removes the needle cap of syringe and pulls plunger to expel air
c. Taps the ampule at the top to allow fluid to flow to the base of the ampule
Question 124
Before discharge, Nurse Loren discusses care at home with Mr. Billiards and his wife. The nurse recognizes that
further teaching is required when the wife says:
a. I have to take his blood pressure every day in the arm with the fistula. have to take his blood pressure every day
in the arm with the fistula.”
b. He will have to be very careful at night not to lie on the arm with the fistula. will have to be very careful at night
not to lie on the arm with the fistula.”
c. I must touch the shunt several times a day to feel for the bruit. must touch the shunt several times a day to feel
for the bruit.”
d. We really should check the fistula every day for signs of redness and swelling.
Question 125