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IFC4 - NURSING PRACTICE 1

(IFC4-NP1-MC1-001-013-J)
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MANAGEMENT OF CARE 1
1. The nurse is assisting with a subclavian vein central
line insertion when the client's oxygen saturation rapidly
drops. He complains of shortness of breath and becomes
tachypneic. The nurse suspects a pneumothorax has
developed. Further assessment findings supporting the
presence of a pneumothorax include:
a. diminished or absent breath sounds on the
affected side
b. paradoxical chest wall movement with
respirations
c. tracheal deviation to the unaffected side.
d. muffled or distant heart sounds.
2. When monitoring a client's central venous pressure
(CVP), the nurse knows that a normal CVP measurement
is:
a. 2 cm water.
b. 1 mm Hg.
c. 10 mm Hg.
d. 5 cm water.
3. During an admission assessment, the nurse asks a
client why he's being admitted to the facility. The client
responds, "The physician found a lump in my prostate
gland. I guess I have cancer." Which response by the
nurse would be most therapeutic?
a. "There is no way to know whether you have
cancer until a biopsy is done."
b. "It isn't unusual for a man your age to have an
enlarged prostate. Try not to worry."
c. "It's important to keep a positive attitude. There
is a good chance it isn't cancer."
d. "You think you have cancer?"
4. A client hospitalized with pneumonia has thick,
tenacious secretions. To help liquefy these secretions,
the nurse should:
a. turn the client every 2 hours.
b. elevate the head of the bed 30 degrees.
c. encourage increased fluid intake.
d. maintain a cool room temperature.
5. The nurse is giving nutritional counseling to the mother
of a child with celiac disease. Which statement by the
mother would indicate understanding?
a. "My son can't eat wheat, rye, oats, or barley."
b. "My son needs a diet rich in gluten."
c. "My son must avoid potatoes, rice, flour, and
cornstarch."
d. "My son can safely eat frozen and packaged
foods."
6. A facility has a system for transcribing medication
orders to a Kardex as well as a computerized medication
administration record (MAR). A physician writes the
following order for a client: "Prednisone 5 mg P.O. daily
for 3 days." The order is correctly transcribed on the
Kardex. However, the nurse who transcribes the order
onto the MAR neglects to place the limitation of 3 days on

the prescription. On the 4th day after the order was

instituted, a nurse administers prednisone 5 mg P.O.
During an audit of the chart, the error is identified. The
person most responsible for the error is the:
a. nurse who transcribed the order incorrectly on the
MAR
b. nurse who administered the erroneous dose.
c. pharmacist who filled the order and provided the
erroneous dose.
d. facility because of its policy on transcription of
medications.
7. A client, age 43, has no family history of breast cancer
or other risk factors for this disease. The nurse should
instruct her to have a mammogram how often
a. Once, to establish a baseline
b. Once per year
c. Every 2 years
d. Twice per year
8. When prioritizing a client's plan of care based on
Maslow's hierarchy of needs, the nurse's first priority
would be:
a. allowing the family to see a newly admitted
client.
b. ambulating the client in the hallway.
c. administering pain medication
d. placing wrist restraints on the client.
9. A client who received general anesthesia returns from
surgery. Postoperatively, which nursing diagnosis takes
highest priority for this client?
a. Pain related to surgery
b. Deficient fluid volume related to blood and fluid
loss from surgery
c. Impaired physical mobility related to surgery
d. Risk for aspiration related to anesthesia
10. When assessing a client with cellulitis of the right leg,
which of the following would the nurse expect to find?
a. Painful skin that is swollen and pale in color
b. Cold, red skin
c. Small, localized blackened area of skin
d. Red, swollen skin with inflammation spreading
to surrounding tissues
11. Which member of the health care team is responsible
for obtaining informed consent from a client?
a. The primary nurse
b. The physician
c. The nurse working with the physician
d. The physician's assistant
12. The nurse is caring for a client with a history of falls.
The first priority when caring for a client at risk for falls is:
a. placing the call light for easy access.
b. keeping the bed in the lowest possible position.
c. instructing the client not to get out of bed without
assistance.
d. keeping the bedpan available so that the client
doesn't have to get out of bed.
13. A client who speaks little English has emergency
gallbladder surgery. During discharge preparation, which
nursing action would best help this client understand
wound care instructions?

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plagiarism, copyright infringement and violation of related laws in connection with the contents of the materials. It had no participation in the preparation and
compilation thereof such being the sole responsibility of the lecturer concerned. This disclaimer serves as a notice to the public that The Big Leap shall not be
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a. Asking frequently whether the client
understands the instructions
b. Asking an interpreter to relay the instructions to
the client
c. Writing out the instructions and having a family
member read them to the client
d. Demonstrating the procedure and having the
client return the demonstration
14. A 49-year-old client with acute respiratory distress
watches everything the staff does and demands full
explanations for all procedures and medications. Which
of the following actions would best indicate that the client
has achieved an increased level of psychological
comfort?
a. Making decreased eye contact
b. Asking to see family members
c. Joking about the present condition
d. Sleeping undisturbed for 3 hours
15. A hospitalized client who has a living will is being fed
through a nasogastric (NG) tube. During a bolus feeding,
the client vomits and begins choking. Which of the
following actions is most appropriate for the nurse to
take?
a. Clear the client's airway.
b. Make the client comfortable.
c. Start cardiopulmonary resuscitation.
d. Stop the feeding and remove the NG tube.
16. The nurse is caring for a geriatric client with a
pressure ulcer on the sacrum. When teaching the client
about dietary intake, which foods should the nurse plan to
emphasize?
a. Legumes and cheese
b. Whole grain products
c. Fruits and vegetables
d. Lean meats and low-fat milk
17. A client with chronic renal failure is admitted with a
heart rate of 122 beats/minute, a respiratory rate of 32
breaths/minute, a blood pressure of 190/110 mm Hg,
neck vein distention, and bibasilar crackles. Which
nursing diagnosis takes highest priority for this client?
a. Fear
b. Urinary retention
c. Excessive fluid volume
d. Self-care deficient: Toileting
18. A client's blood test results are as follows: white blood
cell (WBC) count is 1,000/l; hemoglobin (Hb) level, 14
g/dl; hematocrit (HCT), 42%. Which of the following goals
would be most important for this client?
a. Promote fluid balance
b. Prevent infection.
c. Promote rest.
d. Prevent injury.
19. Which type of evaluation occurs continuously
throughout the teaching and learning process?
a. Formative
b. Retrospective
c. Summative
d. Informative

20. When a nurse enters the room, the client complains

that she's spitting up blood when she coughs. The nurse
takes a quick health history that includes:
a. the history of the present problem, medications,
review of systems, and recent major operations.
b. the history of the present problem, allergies,
medications, and recent major operations.
c. the history of the present problem, medications,
family history, psychosocial history, and review
of systems.
d. the history of the present problem, allergies,
medications, review of systems, and recent
major operations.
21. As a result of a serious motorcycle accident, a client
suffers paraplegia. When the nurse tries to administer
medication, the client refuses it, saying, "I don't have to
take those pills if I don't want to. What good will they do?"
Which action by the nurse would be most appropriate?
a. Insisting that the client take the medication
b. Reporting the client's comments to the physician
c. Explaining the consequences of not taking the
medication
d. Exploring how the client's feelings affect the
decision to refuse medication
22. A client who has been admitted for surgery seems
preoccupied and anxious the night before the operation.
Which comment by the nurse would promote therapeutic
communication?
a. "Are you worried about your surgery tomorrow?"
b. "Would you like me to call a chaplain to talk with
you about any concerns you may have about
surgery?"
c. "You seem worried about something. Would it
help to talk about it?"
d. "It isn't unusual to worry about surgery. If you'd
like, I'll ask the physician for something to help
you sleep."
23. The nurse is reviewing a client's arterial blood gas
(ABG) report. Which ABG value reflects the acid
concentration in the blood?
a. pH
b. PaO2
c. PaCO2
d. HCO3
24. Which of the following is the most common source of
airway obstruction in an unconscious victim?
a. A foreign object
b. Saliva or mucus
c. The tongue
d. Edema
25. When preparing a client for a diagnostic study of the
colon, the nurse teaches the client how to self-administer
a prepackaged enema. Which statement by the client
indicates effective teaching?
a. "I will administer the enema while sitting on the
toilet."
b. "I will administer the enema while lying on my
left side with my right knee flexed."
c. "I will administer the enema while lying on my
right side with my left knee flexed."

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plagiarism, copyright infringement and violation of related laws in connection with the contents of the materials. It had no participation in the preparation and
compilation thereof such being the sole responsibility of the lecturer concerned. This disclaimer serves as a notice to the public that The Big Leap shall not be
liable for any complaints, actions or suits in connection with the contents of the materials of this compilation.

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d. "I will administer the enema while lying on my
back with both knees flexed."
26. A client hasn't voided since before surgery, which
took place 8 hours ago. When assessing the client, the
nurse will:
a. be unable to palpate the bladder.
b. feel that the bladder is smooth.
c. palpate the bladder above the symphysis pubis.
d. palpate the bladder at the umbilicus.
27. After assessing a client, the nurse formulates relevant
nursing diagnoses. Which of the following is a complete
nursing diagnosis statement?
a. Ineffective airway clearance related to mucus
plugs and nonproductive cough
b. Hyperventilation related to anxiety
c. Tachycardia
d. Shortness of breath related to anxiety
28. The nurse is teaching the parents of a child with
cystic fibrosis about proper nutrition. Which of the
following instructions should the nurse include?
a. Encourage a high-calorie, high-protein diet.
b. Restrict fluids to 1,500 ml per day.
c. Limit salt intake to 2 g per day.
d. Encourage foods high in vitamin B.
29. To avoid recording an erroneously low systolic blood
pressure because of failure to recognize an auscultatory
gap, the nurse should:
a. have the client lie down while taking his blood
pressure.
b. inflate the cuff to at least 200 mm Hg.
c. take blood pressure readings in both arms.
d. inflate the cuff at least another 30 mm Hg after
the radial pulse becomes unpalpable.
30. A client, age 68, admitted for treatment of a colon
tumor, asks the nurse, "Do I have cancer?" Which
response by the nurse would be best?
a. "Most people your age develop some type of
colon problem."
b. "Your physician can discuss this in more detail."
c. "You sound concerned about what is
happening."
d. "You'll have to have some tests before cancer
can be ruled out."
31. A client twists the right ankle while playing basketball
and seeks care for ankle pain and swelling. After the
nurse applies ice to the ankle for 30 minutes, which
statement by the client suggests that ice application has
been effective?
a. "I need something stronger for pain relief."
b. "My ankle looks less swollen now."
c. "My ankle appears redder now."
d. "My ankle feels very warm."
32. The nurse is preparing to help a client with weakness
in his right leg get out of bed to a chair. Where should the
nurse place the chair?
a. Parallel to the bed on the right side
b. Perpendicular to the bed on the right side
c. Parallel to the bed on the left side
d. Parallel to the bed on either side

33. A client who recently immigrated to the Philippines

from Korea is hospitalized with second- and third-degree
burns. He speaks little English and has been lying quietly
in bed. Ten hours after his admission, the nurse conducts
a serial assessment and asks him whether he's in pain.
He smiles and shakes his head vigorously back and forth.
Which nursing action would be most appropriate at this
time?
a. Documenting that the client is resting quietly and
denies pain
b. Calling a family member to obtain information
about the client
c. Giving the client the prescribed
d. Checking vital signs and assessing for
nonverbal indications of pain
34. A client scheduled for cardiac catheterization tells the
nurse she is nervous because she has heard of people
dying during this procedure. Which response by the
nurse would be best?
a. "I don't blame you for being nervous. We all
worry
b. "Don't worry. You're in excellent hands."
c. "Why do you feel this way? Do you know
someone who had a problem?"
d. "You sound really upset. Would you like to talk
about it?"
35. Which clinical characteristic affects client
compliance?
a. Drug knowledge
b. Psychosocial factors
c. The nurse-client relationship
d. Disease duration and severity
36. Which intervention should the nurse try first for a
client who exhibits signs of sleep disturbance?
a. Administer sleeping medication before bedtime.
b. Ask the client each morning to describe the
quality of sleep during the previous night.
c. Teach the client relaxation techniques, such as
guided imagery, meditation, and progressive
muscle relaxation.
d. Provide the client with normal sleep aids, such
as pillows, back rubs, and snacks.
37. The nurse is assessing a postoperative client. Which
of the following should the nurse document as subjective
data?
a. Vital signs
b. Laboratory test results
c. Client's description of pain
d. Electrocardiographic (ECG) waveforms
38. Two days after undergoing a modified radical
mastectomy, a client tells the nurse, "Now I won't be
sexually attractive to my husband." Based on this
statement, which nursing diagnosis is most appropriate?
a. Anxiety
b. Disturbed body image
c. Ineffective sexuality patterns
d. Ineffective individual coping
39. The nurse is caring for a child with celiac disease.
How should the nurse evaluate the effectiveness of
nutritional therapy?

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plagiarism, copyright infringement and violation of related laws in connection with the contents of the materials. It had no participation in the preparation and
compilation thereof such being the sole responsibility of the lecturer concerned. This disclaimer serves as a notice to the public that The Big Leap shall not be
liable for any complaints, actions or suits in connection with the contents of the materials of this compilation.

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a. Monitor vital signs every 4 hours.
b. Monitor the appearance, size, and number of
stools.
c. Measure blood urea nitrogen and serum
creatinine levels
d. Measure intake and output.
40. A client is being discharged after cataract surgery.
After providing medication teaching, the nurse asks the
client to repeat the instructions. The nurse is performing
which professional role?
a. Manager
b. Educator
c. Caregiver
d. Client advocate
41. The nurse is caring for a 3-year-old child admitted to
the pediatric unit with acetaminophen poisoning. The
nurse administers syrup of ipecac followed by
acetylcysteine every 4 hours for 72 hours. Which
laboratory findings confirm the effectiveness of the drug
therapy?
a. Alanine aminotransferase and aspartate
aminotransferase
b. Creatine kinase-MB
c. Blood urea nitrogen and serum creatinine
d. Complete blood count
42. A client in her first postpartum month has developed
mastitis secondary to breast-feeding. Her nurse, a mother
who developed and recovered from mastitis after her
third child, says, "I remember the discomfort I had and
how quickly it resolved when I began getting treatment."
The therapeutic communication being used by the nurse
is:
a. clarification.
b. reflection.
c. restating.
d. self-disclosure.
43. The nurse is revising a client's plan of care. During
which step of the nursing process does such revision
take place?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
44. Which of the following laboratory test results is the
most important indicator of malnutrition in a client with a
wound?
a. Serum potassium level
b. Lymphocyte count
c. Albumin level
d. Differential count
45. A client complains of severe abdominal pain. To elicit
as much information as possible about the pain, the
nurse should ask:
a. "Do you have the pain all the time?"
b. "Can you describe the pain?"
c. "Where does it hurt the most?"
d. "Is the pain stabbing like a knife?"

46. The nurse is evaluating a postoperative client for

infection. Which sign or symptom would be most
indicative of infection?
a. The presence of an indwelling urinary catheter
b. Rectal temperature of 100 F (37.8 C)
c. Red, warm, tender incision
d. White blood cell (WBC) count of 8,000/l
47. Which safeguard should the nurse take to ensure
accuracy with a telephone order?
a. Repeat the order to the prescriber.
b. Repeat the order to the nursing supervisor.
c. Wait for the physician to sign the order before
administering the drug.
d. Insist that the nursing supervisor monitor the
call.
48. A scrub nurse in the operating room has which
responsibility?
a. Positioning the client
b. Assisting with gowning and gloving
c. Handing surgical instruments to the surgeon
d. Applying surgical drapes
49. Standard precautions include which of the following
measures?
a. Wearing gloves when changing a dressing
b. Disposing of needles in a puncture-resistant
container
c. Wearing eye protection during tracheal
suctioning
d. All of the above
50. Why should an infant be quiet and seated upright
when the nurse assesses his fontanels?
a. The mother will have less trouble holding a
quiet, upright infant.
b. Lying down can cause the fontanels to recede,
making assessment more difficult.
c. The infant can breathe more easily when sitting
up.
d. Lying down and crying can cause the fontanels
to bulge.

The Big Leap makes no representation about the accuracy, authenticity and reliability of this compilation. It disclaims any and all responsibility or liability for
plagiarism, copyright infringement and violation of related laws in connection with the contents of the materials. It had no participation in the preparation and
compilation thereof such being the sole responsibility of the lecturer concerned. This disclaimer serves as a notice to the public that The Big Leap shall not be
liable for any complaints, actions or suits in connection with the contents of the materials of this compilation.