Professional Documents
Culture Documents
2. To remove soft contact lenses from the eyes of an unconscious patient the nurse should:
A. Uses a small suction cup placed on the lenses
B. Pinches the lens off the eye then slides it off the cornea
C. Lifts the lenses with a dry cotton ball that adheres to the lenses
D. Tenses the lateral canthus while stimulating a blink reflex by the patient
Answer:B
3.A patient undergoes laminectomy. In the immediate post-operative period, the nurse
should
A. Monitor the patient's vital signs and log roll him to prone position
B. Monitor the patient's vital signs and encourage him to ambulate
C. Monitor the patient's vital signs and auscultate his bowel sounds
D. Monitor the patient's vital signs, check sensation and motor power of the feet
Answer:D
4. A patient with duodenal peptic ulcer would describe his pain as:
A. Generalized burning sensation
B. Intermittent colicky pain
C. Gnawing sensation relieved by food
D. Colicky pain intensified by food
Answer:D
5.A patient admitted to the hospital in hypertensive crisis is ordered to receive hydralazine
(Apresoline) 20mg IV stat for blood pressure greater than 190/100 mmHg. The best
response of the
nurse to this order is to:
A. Give the dose immediately and once
B. Give medication if patient's blood pressure is > 190/100 mmHg
C. Call the physician because the order is not clear
D. Administer the dose and repeat as necessary
Answer:A
6. Whilst recovering from surgery a patient develops deep vein thrombosis. The sign that
would indicate this complication to the nurse would be:
A. Intermittent claudication
B. Pitting edema of the area
C. Severe pain when raising the legs
D. Localized warmth and tenderness of the site
Answer:D
8.client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should
the nurse assess first?
A. Blood pressure
B. Respirations
C. Temperature
D. Cardiac rhythm
Answer: D
9.The nurse is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in removing respiratory secretions?
A. Administration of cough suppressants
B. Increasing oral fluid intake to 3000 cc per day
C. Maintaining bed rest with bathroom privileges
D. Performing chest physiotherapy twice a day
Answer is B: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced
with adequate hydration which thins and liquefies secretions.
11.The primary goal of therapy for a client with pulmonary edema and heart failure?
A Enhance comfort
B Improve respiratory status
C Peripheral edema decreased
D Increase cardiac output
Answer: D
12.The nurse is preparing to administer an I.M. injection in a client with a spinal cord injury
that has resulted in paraplegia. Which of the following muscles is best site for the injection
in this case?
A. Deltoid.
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
Answer: A
13. The nurse is to collect a sputum specimen from a client. The best time to collect this
specimen is:
A. early in the evening.
B. anytime during the day.
C. in the morning, as soon as the client awakens.
D. before bedtime.
Answer: C Because sputum accumulates in the lungs during sleep, the nurse should collect
a sputum specimen in the morning, as soon as the client awakens and before he eats or
drinks. This specimen will be concentrated, increasing the likelihood of an accurate culture
14. An obese client has returned to the unit after receiving sedation and electroconvulsive
therapy. The nurse requests assistance moving the client from the stretcher to the bed.
There are 2 people available to assist. Which of the following is the best method of transfer
for this patient?
A. Carry lift.
B. Sliding board.
C. Lift sheet transfer.
D. Hydraulic lift.
Answer:B
Which type of nursing intervention does the nurse perform when she administers oral care
to a client?
A. Psychomotor.
B. Educational.
C. Maintenance.
D. Supervisory.
Answer:c
On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she
has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses
foul-smelling, yellow lochia. What do these findings suggest?
A. Lochia alba
B. Lochia serosa
C. Localized infection
D. Cervical laceration
. What is the term used for normal respiratory rhythm and depth in a client?
A. Eupnea
B. Apnea
C. Bradypnea
D. Tachypnea
QJ1. A client receives a painkiller. Thirty minutes
later , The nurse asks the client if the pain is
relieved. Which step of nursing process the
nurse is using?
A. Assessment
B. Nursing diagnosis
C. Implementation
D. Evaluation
A client says to the nurse "I know that I'm going to die." Which of the following responses
by the nurse would be best?
A. "We have special equipment to monitor you and your problem."
B. "Don't worry. We know what we're doing and you aren't going to die."
C. "Why do you think you're going to die?"
D. "Oh no, you're doing quite well considering your condition."
The nurse is assessing the reflexes of a newborn. The nurse assesses which of the following
reflexes by placing a finger in the newborn’s mouth?
A. Moro reflex
B. Sucking reflex
C. Rooting reflex
D. Babinski reflex
Answer: B
When caring for a patient who has intermittent claudication, a cardiac/vascular nurse
advises the patient to:
A. apply graduated compression stockings before getting out of bed.
B. elevate the legs when sitting.
C. refrain from exercise.
D. walk as tolerated.
Answer: D
The client is brought to the emergency department due to drug poisoning. Which of the
following nursing interventions is most effective in the management of the client’s
condition?
a) Gastric lavage
b) Activated charcoal
c) Cathartic administration
d) Milk dilution
Answer:B Activated charcoal
The administration of activated charcoal is the most effective in the management of
poisoning because it absorbs chemicals in the gastrointestinal tract, thus reducing its
toxicity.
A nurse is assessing a group of clients. The nurse knows that which of the following clients
is at risk for fluid volume deficit?(DHA)
a) Client diagnosed with liver cirrhosis.
b) Client with diminished kidney function.
c) Client diagnosed with congestive heart failure.
d) Client attached to a colostomy bag.
Answer: D
The physician teaches a client about the need to increase her intake of calcium. At a
follow-up appointment, the nurse asks the client which foods she has been consuming to
increase her calcium intake. Which answer suggests that teaching about calcium-rich foods
was effective?
A. Broccoli and nuts
B. Yogurt and kale
C. Bread and shrimp
D. Beans and potatoes
Answer: B
The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the client has
dysphagia (difficulty swallowing). Which intervention by the nurse is best for preventing
aspiration?
A. Placing the client in high Fowler's position to eat.
B. Offering liquids and solids together.
C. Keeping liquids thinned.
D. Placing food on the affected side of the mouth.
Answer: A
When administering an I.M. injection to an infant, the nurse in charge should use which
site?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis
Answer: D
Which organ in the body always recieve the most percentage of blood(%cardiac
output)flow?.(AIIMS,ME,BPSC )
A. Kidney
B. Heart
C. Brain
D. Lung
Answer: D
Lung recieves 100% of cardiac output via both pulmonary & systemic circulation.
A resident is on a bladder retraining program. The nurse aide can expect the resident to
A . Have a fluid intake restriction to prevent sudden urges to urinate.
B . Wear an incontinent brief in case of an accident.
C . Have an indwelling urinary catheter.
D . Have aschedule for toileting.
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided
heart failure?
A. Cyanosis of the lips
B. Bilateral crackles
C. Productive cough
D. Leg edema
Which of the following statements is true about range of motion (ROM) exercises?
A Done just once a day
B Help prevent strokes and paralysis
C Require at least ten repetitions of each exercise
D Are often performed during ADLs such as bathingor dressing
Answer:D
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse
should stress the importance of:
A. restricting fluids.
B. restricting sodium.
C. forcing fluids.
D. restricting potassium.
. When assessing a client with glaucoma, a nurse expects which of the following findings?
A. Complaints of double vision.
B. Complaints of halos around lights.
C. Intraocular pressure of 15 mm Hg.
D. Soft globe on palpation.
In the emergency department, the nurse is caring for a client with type 1 diabetes who was
brought in by ambulance after losing consciousness. Upon assessment, the client's breath
was noted to be fruity. Which of the following ABG results would the nurse expect?
A. pH: 7.49 PCO2: 50 HCO3: 18
B. pH 7.28: PCO2: 40 HCO3: 16
C. pH:7.38 PCO2: 45 HCO3: 26
D. pH: 7.31 PCO2: 60 HCO3: 29
Answer:B
Risk for metabolic acidosis in type1 DM
The nurse is taking the health history of a patient being treated for sickle cell disease. After
being told the patient has severe generalized pain, the nurse expects to note which
assessment finding?
A. Severe and persistent diarrhea
B. Intense pain in the toe
C. Yellow-tinged sclera
D. Headache
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is
most useful in distinguishing acute respiratory distress syndrome from acute respiratory
failure?
A. Partial pressure of arterial oxygen (PaO2)
B. Partial pressure of arterial carbon dioxide (PaCO2)
C. pH
D. Bicarbonate (HCO3–)
Answer: A
The procedure involves removal of the "head" (wide part) of the pancreas, the duodenum, a
portion of the common bile duct, gallbladder, and sometimes part of the stomach.And
anastomosis to jejunum ?
A. Birloth 1procedures
B. Birloth 2 procedures
C. Wipple procedures
D. Subtotal cholecystectomy
Answer: C
A client with a fluid volume deficit is receiving an I.V. infusion of dextrose 5% in water and
lactated Ringer's solution at 125 ml/hour. Which data collection finding indicates the need
for additional I.V. fluids?
A. Serum sodium level of 135 mEq/L
B. Temperature of 99.6° F (37.6° C)
C. Neck vein distention
D. Dark amber urine
Answer: D
Normally, urine appears light yellow; dark amber urine is concentrated and suggests
decreased fluid intake.
Which of the following types of immunoglobulins does not cross the barrier between mother
and infant in the womb?
A. IgA
B. IgM
C. IgD
D. IgE
A 39-year-old forklift operator presents with shakiness, sweating, anxiety, and palpitations
and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the
nurse do first?
A. Inject 1 mg of glucagon subcutaneously.
B. Administer 50 mL of 50% glucose I.V.
C. Give 4 to 6 oz (118 to 177 mL) of orange juice.
D. Give the client four to six glucose tablets
The nurse is collecting data on a male client diagnosed with gonorrhea. Which symptom
likely prompted the client to seek medical attention?
A. Rashes on the palms of the hands and soles of the feet
B. Cauliflower-like warts on the penis
C. Painful red papules on the shaft of the penis
D. Foul-smelling discharge from the penis
A client with B negative blood requires a blood transfusion during surgery. If no B negative
blood is available, the client should be transfused with:
❍A. A positive blood
❍B. B positive blood
❍C. O negative blood
❍D. AB negative blood
Answer: C
If the client’s own blood type and Rh are not available, the safest transfusion is O negative
blood. Answers A, B, and D are incorrect because they can cause reactions that can prove
fatal to the client
An woman is prescribed metformin for glucose control. The patient is on NPO status pending
a diagnostic test. The nurse is most concerned about which side effect of metformin?
A. Diarrhea and Vomiting
B. Dizziness and Drowsiness
C. Metallic taste
D. Hypoglycemia
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis.
What is the best position for this client?
a. Side-lying with knees flexed
b. Knee-chest
c. High Fowler’s with knees flexed
d. Semi-Fowler’s with legs extended on the bed
The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse
effect must the nurse watch for most carefully?
A. Increase in blood pressure
B. Increase in blood volume
C. Low serum potassium level
D. High serum sodium level
Answer: C
Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium
level and assess for signs of low potassium. As water and sodium are lost in the urine, blood
pressure decreases, blood volume decreases, and urine output increases.
The nurse is caring for a client with pneumonia. The physician orders 600 mg of ceftriaxone
(Rocephin) oral suspension to be given once per day. The medication label indicates that the
strength is 150 mg/5ml. How many milliliters of medication should the nurse pour to
administer the correct dose?
A. 2.5 ml
B. 4 ml
C. 10 ml
D. 20 ml
Answer: D
The nurse is preparing to discharge a 70-year-old man on warfarin therapy for a pulmonary
embolism. The nurse’s dischargeteaching should include which of the following instructions?
A.Follow a healthy diet by increasing ingestion of green, leafy vegetables.
B. Take herbal remedies to manage cold symptoms.
C. Avoid alcohol due to enhanced anticoagulant effect.
D. Take Coumadin only on an empty stomach.
During the initial admission process, a geriatric client seems confused. What is the most
probable cause of this client's confusion?
A. Depression
B. Altered long-term memory
C. Decreased level of consciousness (LOC)
D. Stress related to an unfamiliar situation
Answer: D
The stress of being in an unfamiliar situation, such as admission to a hospital, can cause
confusion in geriatric clients. Depression doesn't produce confusion, but it can cause mood
changes, weight loss, anorexia, constipation, and early morning awakening. In geriatric
clients, long-term memory usually remains intact, although short-term memory may be
altered. Decreased LOC doesn't normally result from aging; therefore, it's a less likely cause
of confusion in this client.
The physician orders an I.M. injection for a client. Which factor may affect the drug
absorption rate from an I.M. injection site?
A. Muscle tone
B. Muscle strength
C. Blood flow to the injection site
D. Amount of body fat at the injection site
Answer: C
Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and
strength have no effect on drug absorption. The amount of body fat at the injection site may
help determine the size of the needle and the technique used to localize the site; however,
it doesn't affect drug absorption (unless the nurse inadvertently injects the medication into
the subcutaneous tissue instead of the muscle).
The nursing care plan for a client with decreased adrenal function should include
A. Encouraging activity
B. Placing client in reverse isolation
C. Limiting visitors
D. Measures to prevent constipation
Answer is C: Limiting visitors
Any exertion, either physical or emotional, places additional stress on the adrenal glands
which could precipitate an addisonian crisis. The plan of care should protect this client from
the physical and emotional exertion of visitors.
The nurse is doing a physical assessment and electrocardiogram on an elderly client. Which
finding during the nurse's assessment of the cardiac system is of most concern and
warrants prompt further investigation?
A. S4 heart sound.
B. Increased PR interval.
C. Orthostatic hypotension.
D. Irregularly irregular heart rate.