NURSING PRACTICE I SET A

NURSING PRACTICE I FOUNDATION OF NURSING PRACTICE GENERAL INSTRUCTIONS:

1. This test booklet contains 100 test questions.

2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. 5. This is PRC property. Unauthorized possession, reproduction, and/or sale of this test is punishable by law. Per RA 8981.

INSTRUCTIONS: 1. 3. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box B if your test booklet is Set B.

2. Write the subject title Nursing Practice I on the box provided.

SITUATION: The nurse needs to understand that Basic health practices and health promotion is an essential part of nursing and one of the most important responsibilities of a nurse. The nurse should prioritize teaching, health promotion and primary prevention more than anything else. 1. If you are going to modify your lifestyle, it should begin in: A. Have an active lifestyle, exercising regularly B. Avoiding environmental pollutants C. Recognizing the impact of unhealthy habits D. Lessening visits in some fast food restaurants and limiting junk foods 2. All of these are some behavior modification to the management of stress. EXCEPT: A. Progressive muscle relaxation B. Pharmacotherapy 3. Basic to progressive muscle relaxation is: A. Focusing on an image to relax B. Relaxing muscles from tension 4. C. Use of industrial equipment D. Stopping disturbing thoughts C. Spiritual Meditation D. Guided Imagery

A type of massage that involves a smooth, long and circular stroke used in the abdomen of a client during labor is called: A. Petrissage B. Touch Therapy C. Tapotement D. Effleurage

5.

If you are going to assess an incision, you know that which of the following is a sign of inflammation? A. There is a clear and yellow drainage B. Pallor around the incision C. Red and warm incision D. Brown exudates at incision site

SITUATION: You are recently appointed as a chief nurse in a 100 bed hospital in Manila. As a chief nurse, knowledge of the managerial process is essential.

6. One of the first things that you did was objective writing, formulating goals and philosophy of nursing service. This is an element of which managerial process phase? A. Planning 7. B. Controlling C. Directing D. Organizing

You also come up with the organizational structure defining the role and function of the different nursing positions and line-up the position with qualified people. This is included in which element of the managerial process? B. Evaluation C. Organizing D.

A. Monitoring Planning 8.

After a week, you and the management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration: A. Monitoring B. Organizing C. Controlling D. Planning

9.

Controlling or Evaluation is best defined as: A. A continuing process of seeing that performance meets goals and targets B. Obtaining commitment of members to do better C. Informing personnel how well and how much improvement has been made D. Follow-up of activities that have been studied

10. Which of the following are the two most important skills that a manager should possess? 1. Skills in decision making 3. Skills in communication A. 1 & 3 B. 1 & 4 2. Skills in planning 4. Skills in Auditing C. 1 & 2 D. 2 & 4

SITUATION: Measurement of Vital signs is necessary skill a nurse should possess. Remember that taking Vital signs is one of the most common routine activities that an entry level nurse will do in practice. 11. When taking the oral temperature of a client who smoke or drink hot or cold fluids, it is necessary that the nurse should wait for how many minutes? A. 15 minutes B. 30 minutes C. 5 minutes D. 1 hour

12. When taking the blood pressure, the nurse should properly wait for a period of time when the client has just arrived to the health center. How many minutes should a nurse wait before taking the blood pressure of this client? A. 15 minutes B. 30 minutes C. 5 minutes D. 1 hour

13. The nurse knows that he should pump the cuff of the sphygmomanometer above: A. 15 mmHg based on the Palpatory systolic BP B. 15 mmHg based on the Auscultatory systolic BP C. 30 mmHg based on the Palpatory systolic BP D. 30 mmHg based on the Auscultatory systolic BP

14. The nurse should warp the BP Cuff evenly around the clients arm ensuring that it is well place approximately:

A. 1 cm above the antecubital space B. 1 inch above the antecubital space

C. 4 cm above the antecubital space D. 2 inches above the antecubital space

15. In taking the blood pressure of an obese client, the nurse used an ordinary size cuff and therefore an error will most likely occur. The nurse knows that if this is the case, The Blood Pressure will be: A. False high B. False low C. Undetermined D. Normal

SITUATION: The human body is a complex system of interrelated cells, tissues and organs that performs vital functions necessary to sustain life. Knowledge of basic anatomy is essential to understand how well our body adapts to the demands of life. 16. What gland secretes the human growth hormone or the somatotropin? A. Hypothalamus B. Posterior Pituitary Gland C. Anterior pituitary gland D. Liver

17. The gland responsible for synthesizing and producing vasopressin or anti-diuretic hormone is the: A. Hypothalamus B. Posterior Pituitary Gland C. Anterior pituitary gland D. Pancreas

18. RAAS or the rennin-angiotensin-aldosterone mechanism produces which effect in the body? A. Vasodilation and increase sodium and water reabsorption B. Vasoconstriction and decrease sodium and water reabsorption C. Vasodilation and decrease sodium and water resabsorption D. Vasoconstriction and increase sodium and water reabsoprtion 19. Hematopoiesis in a full grown adult occurs mainly in the: A. Red bone marrow B. Liver C. Yellow bone marrow D. Spleen

20. The respiratory center, which controls respiration, is located in the: A. Medulla Oblongata B. Pons Varolii C. Hypothalamus D. Lungs and Diaphragm

SITUATION: Collaboration with the members of the healthcare team is an essential part of nursing practice. 21. If a client is concerned that he cannot pay the bill in due time, he will need a prompt referral to which department? A. Physician B. Library C. Social Service D. DSWD

22. Agatha has breast cancer and is going through chemotherapy. She was referred by the Oncology nurse to a self-help group of clients with cancer to: A. Have an emotional support B. Be part of a research experiment C. For financial benefits D. For legal benefits

23. The nurse should be aware the dietary department is also an important department in the collaborative team. Patient needing special instructions in their diets are referred to which of the following member of the collaborative team?

A. The physician B. The dietician

C. The nutritionist D. The pathologist

24. When collaborating with other health team members, the best description of Nurse Julies role is: A. Encourages the clients involvement in his care B. Shares and implements orders of the health team to ensure quality care C. She listens to the individual views of the team members D. Helps client set goals of care and discharge 25. Nurse Julie is successful in collaborating with health team members about the care of Mr. Santos. This is because she has the following competencies: A. Communication, trust, and decision making B. Conflict management, trust, negotiation C. Negotiation, decision making D. Mutual respect, negotiation and trust SITUATION: At the OPD, Miss Jean R.N assisted in the Physical examination of one patient for Paracentesis, Lumbar tap and Thoracentesis. 26. What instruction should the nurse include prior to paracentesis? A. B. C. D. Ask the client to drink Ask the client to void Ask the client to be positioned on the unaffected side Ask the client to be positioned on the affected side

27. What is the position of the client prior to lumbar puncture?

A. Quasifetal, flexed position B. Jacknife position

C. Prone position D. Sidelying, on the unaffected side

28. Prior to Thoracentesis, the patient is placed on what position?

A. Orthopneic position B. Prone position

C. Dorsal recumbent position D. Lithotomy position

29. Prior to paracentesis, The client is asked to void first to:

A. Test urine

B. Prevent discomfort

C. Prevent puncture of the bladder D. Prevent puncture of the uterus

30. In lumbar puncture, The flexed position of the patient is to:

A. Achieve comfort B. Provide wide exposure of the back

C. Relax muscles D. Widen the vertebral space

SITUATION: You are a nurse assigned for nutrition education class in your barangay. The following questions deals with teaching clients with regards to improving their health through health promotion. 31. Mr. Rodriguez asks you what is the normal allowable salt intake in a day. Your best response to Rodriguez is: A. B. C. D. 1 teaspoon of salt a day with iodine and sprinkle of monosodium glutamate 5 grams of salt a day or 1 teaspoon of salt a day 1 tablespoon of salt with some fish sauce and soy sauce 1 teaspoon of salt with no fish sauce and soy sauce

32. You would educate Mr. Rodriguez with regards to lowering his salt intake using which of the following instruction EXCEPT:

A. B. C. D.

Eat foods with little or no salt added Limit table salt but condiments is advisable Minimize the intake of tocino, longanisa and other processed foods Use spices, fruits, vegetables and herbs instead

33. Which of the following is the best method of teaching young mothers with regards to nutrition education?

A. Diets limited in salt and fat B. Harmful effects of drugs and alcohol intake
planning 34. The cure of cancer would depend on: A. B. C. D.

C. Commercial preparation of dishes D. Cooking demonstration and meal

Knowing the warning signs of cancer Early detection and early treatment Utilization of alternative medicine Performing Testicular self examination regularly

35. In health education, which of the following is a role of the Nurse? A. B. C. D. Focusing on programs on drug rehabilitation and smoking cessation Educate as many people about warning signs of non-communicable diseases Monitoring client with hypertension Reporting cases of TB, Leprosy, AIDS and other communicable diseases

SITUATION: Aling Aida. 42 years old. is waiting for her doctors appointment at the clinic where you work. 36. You are to interview her as an initial nursing action so that you can. A. Document important data in her client records for health team to read. B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to develop plan of care C. provide solutions to her immediate health concern D. identify the most appropriate nurse diagnosis for her heath problem 37. During the interview, Aida experiences a sharp abdominal pain on the right side of her abdomen. She further tells you that an hour ago, she ate fatty food and this had happened many times before. You will record this as: A. Client complains of intermittent abdominal pain an hour alter eating fatty foods B. After eating fatty food the client experienced severe abdominal pain C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after ingestion of fatty foods. 38. Aida tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced diet for her, you will: A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take plenty of fluids. B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates. C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise. D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.

39. You learn that Aida drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her premenopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation because: A. These products increase calcium loss from the bones B. These products have stimulant effect n the body C. these products encourage increase in sugar consumption D. these products are addicting 40. Health education plan for Aida stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT: A. Cancer B. Osteoporosis C. IDDM D. Cardiovascular diseases

SITUATION: Due to rapid changes in technology, lifestyle of human beings evolved. This lead to the development and evolution of health care services to meet the new demands of the society and nation in general. 41. At present, government hospitals are expected to offer comprehensive health services to include illness prevention and health promotion. In which of the following unit of services are these services integrated? A. Wellness center B. Intensive Care unit C. Rehabilitation Center D. newborn screening unit

42. Which of the following is the MOST recent government initiative to help subsidize the cost of health services for both the employed and the unemployed? A. National Health Insurance Act B. Workers Compensation Act C. Medicare Act D. Magna Carta for Public Health Workers

43. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name a few. Many of these conditions are preventable and have implications are preventable and have implications in the development of which nursing competencies? A. Execution of nsg. procedure and technique B. Therapeutic use of self C. Administration of treatment and medication D. Health education

44. The cost of hospitalization is getting more expensive and unaffordable to many of our people. These facts will MOST LIKELY bring about development in which of the following? A. Acute services B. Managed care services C. Home care services D. Advance practice nursing

45. Which of the following latest trend has expanded health services based on prepaid fees with emphasis on health promotion and illness prevention? A. Government Insurance Plan B. Preferred Provider Organization C. Health Maintenance Organization D. Private Insurance Plan

SITUATION: Safe nursing practice involves an understanding of the law.

46. In the Philippines, this law is: A. The Philippine Nursing Act of 2002 or R.A. 9173

B. the Philippine Nursing Act of 1991 or R.A. 7164 C. IRR or Resolution 425 of 2003 D. Republic Act No. 8981 47. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is responsible for: A. Health promotion and prevention of illness B. Administration of written prescription for treatment and therapies C. Rehabilitative aspect of care D. Collaborating with other healthcare providers for health restoration and alleviation of suffering 48. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Its functions include all EXCEPT: A. Used by nurse experts to define what appropriate nursing practice is in a given situation B. Used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances C. Used to delineate the scope, function and role of the nurse D. Use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields 49. As a standard in ethics, this represents an understanding and agreement to respect another persons right to decide a course his or her own destiny: A. Autonomy B. justice C. Beneficence D. Nonmalifecence

50. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to answer for and stand by ones action refers to: A. Accountability B. Veracity C. Advocacy D. Responsibility

SITUATION: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change, create better ways of providing nursing care and develop new nursing roles. 51. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. Maintain maximum functions B. Reduce the costs of health care C. Promote health habits D. Identify disease symptoms

52. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST? A. Maintain maximum function B. Reduce risk factor C. Promote habits related to health care D. Manage stress 53. By experience, which of the following nursing goals are MOST often overlooked by nurses and other members of the hospital team in the care of their clients in the hospital?

A. Illness prevention B. Health promotion

C. Diagnosis and treatment D. Rehabilitation of patients

54. Which of the following health care agencies is usually family-centered, relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness? A. Non-government organization B. Hospice C. Community health center D. Support group

55. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting? A. Bill of rights as provided in the Philippine Constitution B. Scope of nursing practice as defined in R.A. 9173 C. Patients Bill of Rights (as adopted by American Nurses Association) D. Board of Nursing resolution adopting the Code of Ethics SITUATION: A nurse follows the nursing process to organize and deliver nursing care. Use of the process allows the nurse to integrate elements of critical thinking to make judgments and take actions based on reasons. The following questions will test your knowledge regarding the nursing process.

56. One aspect of implementation related to drug therapy is:

A. Developing a content outline. B. Documenting drugs given.

C. Establishing outcome criteria D. Setting realistic client goals

57. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:

A. Change his own dressing. B. Walk in the hallway. C. Walk from his room to the end of the hall and back before discharge. D. Eat a special diet.

58. Which client characteristic would be an example of noncompliance?

A. Undesired drug action B. Multiple questions

C. Failure to progress D. Resolved symptoms

59. A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

A. "I can still eat a ham-and-cheese sandwich with potato chips for lunch."

B. "I chose broiled chicken with a baked potato for dinner." C. "I chose a tossed salad with sardines and oil and vinegar dressing for lunch." D. "I'm glad I can still have chicken bouillon soup."

60. When developing a plan of care for an older adult, the nurse should consider which challenges faced by clients in this age-group?

A. Selecting vocation, becoming financially independent, and managing a home B. Developing leisure activities, preparing for retirement, and resolving empty-nest crisis C. Managing a home, developing leisure activities, and preparing for retirement D. Adjusting to retirement, deaths of family members, and decreased physical strength

61. A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should formulate which nursing diagnosis?

A. Deficient knowledge related to food restrictions associated with anesthesia B. Fear related to surgery C. Risk for impaired skin integrity related to upcoming surgery D. Ineffective individual coping related to the stress of surgery

62. Each morning, the nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the tasks should have been completed anyway. Which leadership style is the nurse-manager exhibiting?

A. Democratic

B. Permissive

C. Laissez-faire

D. Authoritarian

63. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

A. Deficient fluid volume B. Excessive fluid volume

C. Decreased cardiac output D. Ineffective tissue perfusion

64. A client with shock brought on by hemorrhage has a temperature of 97.6 F (36.4 C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order?

A. "Monitor urine output every hour."

B. "Infuse I.V. fluids at 83 ml/hour." C. "Administer oxygen by nasal cannula at 3 L/minute." D. "Draw samples for hemoglobin and hematocrit every 6 hours."

65. When caring for a client, the nurse must determine whether the client has achieved the goals established in the plan of care. The nurse determines goal achievement during which step of the nursing process?

A. Evaluation

B. Planning

C. Implementation

D. Assessment

66. During the planning step of the nursing process, the nurse performs which activity?

A. Records data B. Develops goals of care

C. Collects data D. Carries out interventions

67. When documenting information in a client's medical record, the nurse should:

A. Erase any errors. B. Use a #2 pencil. C. Leave one line blank before each new entry. D. End each entry with the nurse's signature and title

68. When performing an assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?

A. Health-seeking behavior B. Impaired mobility

C. Disturbed sensory perception D. Deficient knowledge

69. Which source of information helps the nurse formulate nursing diagnoses for a specific client?

A. Research articles B. Essential assessment data

C. Outcome criteria D. Admission criteria

70. A client must learn to use a walker. Acquisition of this skill will require learning in the:

A. Cognitive domain B. Affective domain

C. Psychomotor domain D. Attentional domain

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SITUATION: The skills of physical assessment and examination provide nurses with powerful tools to detect subtle, as well as obvious, changes in a clients health. Physical assessment enables the nurse to assess patterns reflecting health problems and to evaluate the clients progress following therapy. The following questions pertain to the physical assessment.

The first technique the nurse employs when conducting a clients physical examination is:

A. Palpation

B. Inspection

C. Percussion

D. Auscultation

The main reason that auscultation preceeds palpation of abdomen is to:

A. Prevent distortion of vascular sounds B. Prevent distortion of bowel sounds

C. Determine any areas tenderness or pain D. Allow the client to relax and be comfortable

To correctly palpate the clients skin for temperature, the nurse will use the:

A. Base of the hands B. Fingertips of the hands

C. Dorsal surface of the hands D. Palmar surface of the hands

To assess a clients superficial lymph nodes, the nurse would:

A. Deeply palpate using the entire hand B. Deeply palpate using a bimanual technique C. Lightly palpate using a bimanual technique D. Gently palpate using the pads of the index and middle fingers

The nurse is teaching the client to inspect all skin surface and to report pigmented skin lesions that:

A. Are symmetrical B. Have irregular borders

C. Are uniform in color D. Are less than 6 mm in diameter

76. The client is being assessed for range of joint movement. You ask the client to move the arm away from the body, evaluating the movement of:

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A. Flexion

B. Extension

C. Abduction

D. Adduction

77.

When inspecting the adult clients thorax, the nurse observes for:

A. Presence of fremitus B. Presence of breath sounds

C. Movement of the diaphragm D. Symmetry of chest excursion

The nurse is auscultating the clients lung fields. The systematic pattern used for comparison is:

A. Side to side B. Top to bottom

C. Anterior to posterior D. Interspace to interspace

The nurse asks the client to interpret the saying Dont count your chickens before theyre hatched.

A. Judgment B. Knowledge

C. Association D. Abstract reasoning

The nurse is conducting a general survey on an adult client. The general survey includes:

A. Appearance and behavior B. Measurement of vital signs C. Observing specific body systems D. Conducting a detailed health history SITUATION: medication is a substance used in the diagnosis, treatment, cure, relief, or prevention of health alterations. No matter where clients receive their health care hospitals, clinics, or home, the nurse plays an essential role in medication preparation and administration, medication teaching, and evaluating clients responses to medications. The following questions will gauge your knowledge about medications. 81. Which of the following rights has been added to the traditional five rights of medication administration?

A. Right documentation B. Right route

C. Right medication D. Right time

82. The nurse is having difficulty reading a physicians order for a medication. The nurse knows the physician is very busy and does not want to be called. The nurse should:

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A. Call a pharmacist to interpret the order B. Call the physician to have the order clarified C. Consult the unit manager to help interpret the order D. Ask the unit secretary to interpret the physicians handwriting

83. The client has an order for 2 tablespoons of Milk of Magnesia. The nurse converts this dose to the metric system and would give the client:

A. 2 ml

B. 5 ml

C. 16 ml

D. 30 ml

Most medication errors occur when the nurse:

A. Fails to follow routine procedures B. Is responsible in administering numerous medications. C. Is caring for too many clients D. Is administering unfamiliar medications.

85. A client is to receive cephalexin (Keflex) 500mg PO. The pharmacy has sent 250 mg tablets. The nurse should give:

A. tablet

B. 1 tablet

C. 1 tablet

D. 2 tablets

86. The nurse is responsible for following legal provisions when administering controlled substances or narcotics. Failure to do so may result in:

A. Fines, imprisonment, and loss of nurse licensure B. Loss of employment C. Medication errors D. Poor health outcomes resulting from narcotic use.

Pharmacokinetics is the study of how medications:

A. Are derived from plants B. Enter the body, reach their site of action, are metabolized, and exit the body.

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C. Are used for certain disease processes. D. Are manufactured and distributed to pharmaceutical companies.

88. A nurse is going to teach a client how to perform a breast self examination. The behavioral objective that would best measure that the clients ability to perform the examination is:

A. The client will verbalize the steps involved in breast self examination within 1 week. B. The nurse will explain the importance of performing breast self examination once a month. C. The client will perform breast self examination on herself before the end of the teaching session. D. The nurse will demonstrate breast self examination on a breast model provided by the American Cancer Association.

89. The nurse is teaching parenting class to a group of pregnant adolescents and has given the adolescents baby dolls to bathe and talk to. This is an example of:

A. Discovery B. An analogy

C. Role playing D. A demonstration

90. A client who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. The best teaching method would be:

A. Demonstration B. Group instruction

C. One on one discussion D. Simulation

SITUATION: Regular elimination of bowel waste products is essential for normal body functioning. Alterations in elimination are often early signs or symptoms of problems within either the gastrointestinal or another body system. The following questions are about bowel elimination. 91. Most nutrients and electrolytes are absorbed in the:

A. Colon

B. Stomach

C. Esophagus

D. Small intestine

92. During the nursing assessment the client reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms might be associated with:

A. Food allergy B. Irritable bowel

C. Lactose intolerance D. Increased peristalsis

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93. The nurse is assessing a 55 year old client who is in the clinic for a routine physical examination. The nurse instructs the client to obtain fecal occult blood testing (FOBT):

A. When there is a family history of polyps B. If client reports rectal bleeding. C. If a palpable mass is detected on digital examination. D. As part of routine examination for colon cancer.

94.

These agents decrease intestinal muscle tone to slow passage of feces.

A. Antidiarrheal opiate agents B. Hypertonic

C. Cathartics D. Laxatives

Diarrhea that occurs with fecal impaction is the result of:

A. A clear liquid diet B. Irritation of the intestinal mucosa

C. Seepage of stool around the impaction D. Inability of the client to form a stool

96. A cleaning enema is ordered for a 55 year old client before intestinal surgery. The maximum amount given is:

A. 150 to 200 ml

B. 200 to 400 ml

C. 400 to 750 ml

D. 750 to 1000 ml

97. Which of the following is true with regards to enema?

A. High cleansing enema can is held 18 inches above the insertion point B. Low cleansing enema cleanses the entire colon, from the anus and rectum up to the ileocecal valve C. Low cleansing enema uses 1,000 ml of irrigating solution D. High cleansing enema is usually performed to cleanse the anus, rectum, sigmoid colon and a portion of the descending colon.

98. During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The nurses actions are to:

A. Stop the instillation B. Slow down the rate of instillation

C. Stop the instillation and obtain vital signs D. Tell the client to breathe slowly and relax

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One of the greatest problems in caring for a client with an NG tube is:

A. Dehydration B. Maintaining comfort C. Constipation D. Nutritional therapy

A nurse trained to care for ostomy clients is a/an:

A. Enterostomal therapist B. Nurse practitioner C. Ostomy practitioner D. GI therapist

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