1.    Answer D.  Administering eye drops should be done in the lower conjunctival sac to ensure that the medication gets to eye. Option A is not done since some medications can irritate the cornea when placed directly in to it. Options B and C are not practiced because doing so cannot hold the medication into the eye. Its tendency would be, the medication would run out or flow out of the eyes.
2.    Answer A. Infiltration happens when the intravenous fluid does not enter the veins, instead it is diffused in the areas outside the vein which explains why the area is swollen and cool to touch. Option B happens when there is there is an inflammation of the vein in the site. It is characterized by pain, swelling, redness and it is warm to touch. Option C is manifested by pain, swelling, warm to touch, redness and fever is present in the client. Option D is expected when the client complains of feeling pain in the IV site and that you can see in the IV tubing that it is filled with air.
3.    Answer B. It is a priority nursing action to first assess the client’s IV site before doing anything. Once there is a report of pain in the site, plus edema and erythema, we check for the patency of the IV site, if it is not patent, then we discontinue the IV and apply warm compress to the IV site to lessen swelling. Options A and D are incorrect because such actions will not relieve the client from pain, edema and erythema. Option C is not indicated because there is no accurate indication that there is a bacterial infection in the site.
4.    Answer B. Quantity= desired dose/ available dose       0.125/ 0.25 = 0.5 tab. The nurse should dispense ½ tablet of Digoxin. Options A, C and D are all incorrect answer.
5.    Answer B. 41.66 or 42 gtts/min           
6.    Answer D. When a nurse is caring for quite a number of patients, to prevent the spread of infections among patients, she should know who are the possible carrier of infections and those who are at risk of acquiring one. Options A, B and C are inappropriate infection preventions that are indicated in this situation.
7.    Answer A. Stool for ova and parasites does not require a sterile technique because we are after for the presence of ova and parasites. And if we are looking for the presence of bacteria in the stool, sterile technique is not still utilized because normally there will be a lot of bacteria in the stool. Options B, C and D require a sterile technique in order to identify what bacterial growth is present in the specimen.
8.    Answer C. The patient is at greater risk of wound infection when he is punctured by a nail in the foot. He is at risk for acquiring tetanus infection once he is not given with tetanus toxoid immunization. The wound the nail creates is quite deep thus there is a great risk for infection. In the case of Option A, patients with colostomy is often given with antibiotics. Options B and D are incorrect because the wound created is not quite deep.
9.    Answer C. The skin is the first line of defense of the body against the infections. In cases of burns more than 20% of the body, this defense is weakened thus the person is greatly predisposed to developing different kinds of infection. Burns does not only affect the ability of the skin to defend the body but it also alters the immunity of the body. Options A, B and D may predispose a patient from the development of infections but cannot be considered as great as compared to burns.
10.    Answer C. Heat loss is achieved through different methods. Conduction happens when there is a direct contact of a material in the skin to achieve heat loss. In this case heat loss is achieved with the use of cooling blanket. Option A is achieved when body heat is diffused away from the body into the air via skin. Option B is achieved by moving air away from the body to replace the warmth the body has with the use of a fan. Option D is achieved with the use of water such as in tepid sponge baths.
11.    Answer C. The stages of grief includes: Denial, Anger, Bargaining, Depression and Acceptance. The stage of denial is when the patient is unable to acknowledge the existence of the diagnosis. In this stage, the patient would seek more opinions from other doctors because she cannot accept the fact of her diagnosis. Options A and D are an example of the stage anger, in which she asks a lot of questions regarding the reason of her sickness. Option D shows the acceptance of the patient.
12.    Answer A. Touching to provide support is a form of therapeutic communication. The use of touch reinforces caring feelings. Option B is non therapeutic. Option C is incorrect because the nurse is not in the position to tell the patient’s family of her prognosis. It is only done by the patient or when the patient requests the nurse to do so. Option D may correct but is not the best answer indicated in this situation.
13.    Answer C. Mrs. Estrada is undergoing the process of depression which is a normal in coping with the grief process. In order to be therapeutic for this patient, the nurse should accept this behavioural adaptation of the patient, since it is just normal. Options A, B and D are non therapeutic because this conditions do not allow the normal process of grieving.
14.    Answer C. The patient is experiencing fear because she herself has seen how her father died in the same age as she has in the present. Options A, B and D may be correct but are not indicated in the situation presented.
15.    Answer B. Bargaining is the stage when the patient tries new things in order for her to lengthen her life. She is willing to try therapies ranging from the conventional to non conventional methods of treating her cancer. Other options do not describe the grieving stage that Mrs. Estrada is experiencing.
16.    Answer B. The Licensure of Registered Professional Nurses protects its main consumers which are the patients. Other options are not the reason as to why nurses undergo licensing.
17.    Answer C. Incident reports are filled out in order to record details of unusual events occurring in the hospital and care of patients. In this case, the incident report is filled out in order to have an available data for quality control analysis and in the future when dealing with legal liabilities. Options A, B and D are incorrect because these are not the reason as to why nurses fill out incident reports.
18.    Answer A. Assault is threatening or attempting to inflict injuries to the patient. The verbalization of the nurse clearly shows that it is a case of an assault. Option B is touching the patient without consent. This is done by pinching or slapping the patient. Options C and D are forms of violations that the nurse can commit to a patient in line with the patients profession.
19.    Answer B. This is a case where the nurse committed an assault as manifested by the threatening behaviour of the nurse. Option A is achieved when you speak ill of a person. Option B is putting the threatening behaviour into action. Option D is committed when one talks ill of another through writing it in a published form.
20.    Answer C. Living will is a legal document that an individual uses to make known his wishes to prolong his life. It is also known as advanced directives. In this case, a living will gives consent to perform life sustaining medical intervention to prolong life in cases of emergency. Other options presented are incorrect because they do not describe what a living will is all about.
21.    Answer C. Consents allow the physician to do the medical procedures indicated for the patient. Prior to procedure, it is the doctor’s responsibility to obtain the patient’s consent and it is the responsibility of the nurse to let the patient sign the consent prior to the surgical procedure. Consent unsigned is like consent not given so it is a must that the nurse should tell the situation to the doctor performing the surgery. Options A, B and D are incorrect because they violate the legalities of the consent.
22.    Answer B. The owner of the chart is the patient himself so it is a must that before authorizing any individual to view the chart, authorization should secured and have someone review the chart with the patient’s physician cousin. Options A, C and D are the incorrect way of dealing such situations involving the patient’s chart.
23.    Answer C. When restraints are applied, it is a must for the nurse to assess the quality of the patient’s skin where the restraint is applied. The priority assessment should be done by assessing the patient’s capillary refill so as to ensure circulation of the extremity. Capillary refill of less than two seconds shows that there is a good circulation in that area. Options A, B and D are signs that the restraints applied are having negative effects to the patient’s extremity.
24.    Answer A. It is the preferred answer because right there in then you will be able to stop the discussion of the patient’s case in front of a lot of people. Option B may be correct because you are saving from humiliation the nursing assistance but it is not the preferred answer because doing so will allow further discussion of the case and more harm will be committed. Option C may be correct because in the first place you are not their immediate superior but not appropriate in this situation because it will further the discussion of the case thus allowing a lot of people to overhear it. Option D is the worst thing to do since you will not do anything to prevent it from happening.
25.    Answer A.Good Samaritan Act protects those who choose to lend a hand during emergency situations. In this act, the nurse is not liable to any laws once she helps an injured individual during this emergency. Options B, C and D are incorrect because these do not explain what the act is all about.

Situation: One important legal and safe nursing responsibility is concerned with administration of medications.

1.    A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops 4 times a day. The nurse should administer the medication on to which of the following areas?
a.    Center of the cornea
b.    Sclera by the inner canthus
c.    C. Sclera by the outer canthus
d.    Lower conjunctival sac

2.     While assessing the client’s intravenous (IV) line, the nurse notes that the area is swollen and cool, causing the client discomfort. The nurse suspects which of the following problems:
a.    Infiltration
b.    Phlebitis
c.    Infection
d.    Air embolism

3.     The client is receiving a 5% dextrose in 0.45% NaCl intravevenously (IV) and report pain at the site, the nurse assesses the site and notes erythema and edema. What would be the appropriate action for the nurse to take?
a.    Slow the infusion rate
b.    Discontinue the IV and apply a warm compress to the IV site
c.    Apply antibiotic ointment to the IV site
d.    Gently pull back the IV access device to reposition it within the vein

4.    A patient’s medication order is to take digoxin 0.125 mg p.o. q.i.d. The nurse has on hand Lanoxin 0.25 mg tablet. The best course of action is to:
a.    Dispense 1 ½ tab
b.     Dispense ½ tab
c.     Dispense 2 tablets
d.     Return the medication to the pharmacy

5.    The patient is ordered 2000 ml of Lactated Ringer’s over 12 hours. The drop factor is 15gtts/ml. The nurse will regulate the IV to how many gtts/min?
a.    28 gtts/min
b.    42 gtts/min
c.    56 gtts/min
d.    14 gtts/min

Situation: The nurse is caring for a group of hospitalized patients.

6.    What should the nurse do first to prevent patient infections?
a.    Provide small bedside bags to dispose of used tissues
b.    Encourage staff to avoid coughing near patients
c.    Administer antibiotics as ordered
d.    Identify patients at risk

7.    The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique?
a.    Stool for ova and parasites
b.    Specimen for a throat culture
c.     Urine from a retention catheter
d.    Exudate from a wound for culture and sensitivity

8.    The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
a.    Surgical creation of a colostomy
b.     First degree burn on the back
c.     Puncture of a foot by a nail
d.     Paper cut on the finger

9.    The nurse understands that the factor that places a patient at the greatest risk for developing an infection is:
a.    Implantation of a prosthetic device
b.    Presence of an indwelling catheter
c.    Burns more than twenty percent of the body
d.    Multiple puncture sites from laparascopic surgery

10.    The nurse is caring for a patient with high fever secondary septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieved heat loss via:
a.    Radiation
b.    Convection
c.    Conduction
d.    Evaporation

Situation: The nurse is caring for Mrs. Estrada who has recently diagnosed with advanced cancer.

11.    Which statement reflects Kubler-Ross stage of denial in the grief process?
a.    “Why this have to happen to me now?”
b.    “My daughter will live with my sister after I am gone”
c.    “Maybe they mixed up my records with someone else’s”
d.    “How could this happen to me when I quit smoking cigarettes?”

12.     After the physician has informed Mrs. Estrada that her cancer is inoperable and the prognosis is poor, the patient begins to cry. The nurse should:
a.    Touch the patient’s hand to provide support
b.    Leave the room to give the patient privacy to cry
c.    Telephone the patient’s family to inform them of the diagnosis
d.    Ask the patient how she feels to encourage ventilation of feelings

13.    Mrs. Estrada became withdrawn and depressed. The nursing action that is most therapeutic is:
a.    Assisting the patient to focus on positive thoughts daily
b.    Explaining that the patient still accomplish goals
c.    Accepting the patient’s behavioral adaptation
d.    Offering the patient advice when appropriate

14.    Which is the most appropriate inference made by the nurse when a patient says, “I’m the same age as my father when he died. Am I going to die of my cancer?” The patient is experiencing:
a.    Grieving associated with perceived impending death
b.    Powerlessness associated with feelings of loss of control
c.    Fear associated with perceived threat to biological integrity
d.    Ineffective coping associated with inadequate psychological resources

15.    Mrs. Estrada is now willing to try new therapies. The nurse identifies that the patient is in what stage of Kubler-Ross’ stages of grieving?
a.    Denial
b.    Bargaining
c.    Depression
d.    Acceptance

Situation: The nurse should be aware of the legal principles associated with nursing practice.

16.    Licensure of Registered Professional Nurses is required necessarily to protect:
a.    Nurses
b.    Patients
c.    Common law
d.    Health care agencies

17.    A patient falls while getting out of bed unassisted. When completing and Incident Report, the nurse understands that it main purpose is to:
a.    Ensure that all parties have an opportunity to document what happened
b.    Help establish who is responsible for the incident
c.    Make available data available for quality control analysis
d.    Document the incident on the patient’s chart

18.    The nurse says. “If you do not let me do this dressing change, I will not let you eat dinner with other residents in the dining room”. This is an example of :
a.    Assault
b.    Battery
c.    Negligence
d.    Malpractice

19.    An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, “If you keep ringing, there will come a time I won’t answer the bell.”This is an example of:
a.    Slander
b.    Assault
c.    Battery
d.    Libel

20.    A patient asks the nurse, “What is a Living Will?” the nurse should respond that it is a document that:
a.    Instructs a physician to withhold/withdraw life-sustaining procedures if death is near
b.    Enables a person to request medication to end life in a humane and dignified manner
c.    Gives consent to perform life-sustaining medical intervention during an emergency
d.    Wills ones organs to help others who need a transplant to sustain life

Situation: As a nurse you must be responsible for the needs of your client.

21.    Ms. R has been medicated for her surgery. The operating room (OR) nurse, when going through the client’s chart, realizes that the consent form has not been signed. Which of the following is the best action for the nurse to take?
a.    Assume it is emergency surgery and the consent is implied
b.    Give the consent form and have the client sign it
c.    Tell the physician that the consent form is not signed
d.    Have a family member sign the consent form

22.    Ms. R is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart. Which of the following is the best response for the nurse to take?
a.    Hand the cousin the client’s chart to review
b.    Ask Ms. R to sign an authorization, and have someone review the chart with the cousin
c.    Call the attending physician and have the doctor speak with his cousin
d.    Tell the cousin that the request cannot be granted

23.    Ms. R has had both wrists restrained because she is agitated and pulls out her IV lines. Which of the following would the nurse observe if Ms. R is not suffering any ill effects from the restraints? That:
a.    She has difficulty moving her fingers and making a fist
b.    Her skin is reddened where the limits were tied around her wrist
c.    Ms. R’s capillary refill is less than two seconds
d.    The client complains of numbness and tingling in her hand

24.    The nurse is in the hospital’s public cafeteria and hears two nursing assistants talking about Ms. R in 406. They are using her name and discussing intimate details about her illness. Which of the following actions is best for the nurse to take?
a.    Go over and tell the nursing assistants that their actions are inappropriate, especially in  public place
b.    Wait and tell the assistants later that they were overheard discussing the client. Otherwise, they might be embarrassed.
c.    Tell the nursing assistants’ supervisor about the incident. It is the supervisor’s responsibility to address the issue
d.    Say nothing. It is not the nurse’s job and she is not responsible for the assistants’ actions

25.    A nurse comes up a motor vehicle accident when driving to work. The nurse administers care to the people involved. Under the Good Samaritan Act, the nurse could be liable:
a.    For nothing, any action is covered
b.    For gross negligence
c.    For not providing the standard care found in the hospital
d.    For not stopping and offering care

Answers and Rationale

More nclex review questions coming up.

1. Answer B. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.
2. Answer B. Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
3. Answer D. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
4. Answer B. The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
5. Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
6. Answer D. The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
7. Answer D. Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.
8. Answer A. When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
9. Answer D. During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
10. Answer C. Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
11. Answer B. Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
12. Answer B. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
13. Answer D. The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail.
14. Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
15. Answer C. Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
16. Answer D. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
17. Answer B. According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
18. Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
19. Answer D. Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
20. Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
21. Answer B. The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
22. Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
23. Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
24. Answer A. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
25. Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
26. Answer B. The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
27. Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
28. Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
29. Answer A. People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
30. Answer D. Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.
    

More NCLEX Review soon…

2.    The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
a.    Auscultation
b.    Inspection
c.    Percussion
d.    Palpation

3.    Which statement regarding heart sounds is correct?
a.    S1 and S2 sound equally loud over the entire cardiac area.
b.    S1 and S2 sound fainter at the apex
c.    S1 and S2 sound fainter at the base
d.    S1 is loudest at the apex, and S2 is loudest at the base

4.    The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
a.    Assessment
b.    Nursing diagnosis
c.    Planning
d.    Evaluation

5.    A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
a.    Fresh, green vegetables
b.    Bananas and oranges
c.    Lean red meat
d.    Creamed corn

6.    The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
a.    Lethal arrhythmias
b.    Malignant hypertension
c.    Status epilepticus
d.    Bone marrow suppression

7.    A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
a.    Impaired gas exchanges related to increased blood flow
b.    Fluid volume excess related to peripheral vascular disease
c.    Risk for injury related to edema
d.    Altered peripheral tissue perfusion related to venous congestion

8.    When positioned properly, the tip of a central venous catheter should lie in the:
a.    Superior vena cava
b.    Basilica vein
c.    Jugular vein
d.    Subclavian vein

9.    Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
a.    Assessment
b.    Planning
c.    Implementation
d.    Evaluation

10.    A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
a.    “The contraction phase of wound healing can take 2 to 3 years.”
b.    “Wound healing is very individual but within 4 months the scar should fade.”
c.    “With your history and the type of location of the injury, it’s hard to say.”
d.    “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”

11.    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

12.    A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
a.    A history of increased aspirin use
b.    Recent pelvic surgery
c.    An active daily walking program
d.    A history of diabetes

13.    Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
a.    Administer sleeping medication before bedtime
b.    Ask the client each morning to describe the quantity of sleep during the previous night
c.    Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
d.    Provide the client with normal sleep aids, such as pillows, back rubs, and snacks

14.    While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
a.    Dry sterile dressing
b.    Sterile petroleum gauze
c.    Moist, sterile saline gauze
d.    Povidone-iodine-soaked gauze

15.    A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
a.    Unbundling
b.    Overbilling
c.    Upcoding
d.    Misrepresentation

16.    A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
a.    Encourage the client to ask questions about personal sexuality
b.    Provide time for privacy
c.    Provide support for the spouse or significant other
d.    Suggest referral to a sex counselor or other appropriate professional

17.    Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
a.    Security
b.    Elimination
c.    Safety
d.    Belonging

18.    A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
a.    Inadequate vitamin D intake
b.    Inadequate protein intake
c.    Inadequate massaging of the affected area
d.    Low calcium level

19.    A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
a.    Acute 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

20.    Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
a.    Extravasation
b.    Osteomalacia
c.    Petechiae
d.    Uremia

21.    Which document addresses the client’s right to information, informed consent, and treatment refusal?
a.    Standard of Nursing Practice
b.    Patient’s Bill of Rights
c.    Nurse Practice Act
d.    Code for Nurses

22.    If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
a.    Fail to show changes in blood pressure
b.    Produce a false-high measurement
c.    Cause sciatic nerve damage
d.    Produce a false-low measurement

23.    Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
a.    Baked beans, hamburger, and milk
b.    Spaghetti with cream sauce, broccoli, and tea
c.    Bouillon, spinach, and soda
d.    Chicken cutlet, spinach, and soda

24.    A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
a.    Assess the client’s airway
b.    Provide pain relief
c.    Encourage deep breathing and coughing
d.    Splint the chest wall with a pillow

25.    A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
a.    Unhappiness about the charge in leadership
b.    Unexpected feeling and emotions among the staff
c.    Fatigue from overwork and understaffing
d.    Failure to incorporate staff in decision making

26.    A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
a.    Promote fluid balance
b.    Prevent infection
c.    Promote rest
d.    Prevent injury

27.    Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
a.    Semi-Fowler’s
b.    Supine
c.    High-Fowler’s
d.    Side-lying

28.    Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
a.    Anisocoria
b.    Ataxia
c.    Cataract
d.    Diplopia

29.    The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
a.    He may have a low threshold for pain
b.    He was faking pain
c.    Someone else gave him medication
d.    The pain went away
30.    A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
a.    A neck tumor
b.    An electrolyte imbalance
c.    Dehydration
d.    Fluid overload

Answers and Rationale

More NCLEX Review coming up…

1. Answer B. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.
2. Answer C. The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
3. Answer C. Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
4. Answer C. A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
5. Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
6. Answer A. Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
7. Answer B. After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
8. Answer D. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
9. Answer A.  As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
10. Answer B. Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
11. Answer B. When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.
12. Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.
13. Answer C. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
14. Answer C. The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
15. Answer C. The nurse solves the problem as follows:

	10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ¾ ml

16. Answer C. To convert Fahrenheit degrees to centigrade, use this formula:

	C degrees = (F degrees – 32) x 5/9 C degrees = (102 – 32) 5/9 + 70 x 5/9 38.9 degrees C

17. Answer D. All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
18. Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
19. Answer C. In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
20. Answer D. The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.
21. Answer A. Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves.
22. Answer A. When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.
23. Answer C. The nurse should give ½ ml of the drug. The dosage is calculated as follows:

	250 mg/X=500 mg/1 ml 500x=250 X=1/2 ml

24. Answer C. Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.
25. Answer A. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.
26. Answer C. The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.
27. Answer A. The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.
28. Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:

	125/60 min = X/1 minute 60X = 125X = 2.1 ml/minute To find the number of drops/minute: 2.1 ml/X gtts = 1 ml/15 gtts X = 32 gtts/minute, or 32 drops/minute

29. Answer A. Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
30. Answer D. During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.

More NCLEX Questions soon…

2.    When examining a patient with abdominal pain the nurse in charge should assess:
a.    Any quadrant first
b.    The symptomatic quadrant first
c.    The symptomatic quadrant last
d.    The symptomatic quadrant either second or third

3.    The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
a.    Vital signs
b.    Laboratory test result
c.    Patient’s description of pain
d.    Electrocardiographic (ECG) waveforms

4.    A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
a.    A palpable radial pulse
b.    A palpable ulnar pulse
c.    Cool, pale fingers
d.    Pink nail beds

5.    Which of the following planes divides the body longitudinally into anterior and posterior regions?
a.    Frontal plane
b.    Sagittal plane
c.    Midsagittal plane
d.    Transverse plane

6.    A female patient with a terminal illness is in denial. Indicators of denial include:
a.    Shock dismay
b.    Numbness
c.    Stoicism
d.    Preparatory grief

7.    The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
a.    Position the head of the bed flat
b.    Helps the patient dangle the legs
c.    Stands behind the patient
d.    Places the chair facing away from the bed

8.    A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
a.    Asking frequently if the patient understands the instruction
b.    Asking an interpreter to replay the instructions to the patient.
c.    Writing out the instructions and having a family member read them to the patient
d.    Demonstrating the procedure and having the patient return the demonstration

9.    Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
a.    Discard the syringe to avoid a medication error
b.    Obtain a label for the syringe from the pharmacy
c.    Use the syringe because it looks like it contains the same medication the nurse was prepared to give
d.    Call the day nurse to verify the contents of the syringe

10.    When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
a.    Faster drug clearance
b.    Aging-related physiological changes
c.    Increased amount of neurons
d.    Enhanced blood flow to the GI tract

11.    A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
a.    Manager
b.    Educator
c.    Caregiver
d.    Patient advocate

12.    A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
a.    “Everything will be fine. Don’t worry.”
b.    “Read this manual and then ask me any questions you may have.”
c.    “Why don’t you listen to the radio?”
d.    “Let’s talk about what’s bothering you.”

13.    A scrub nurse in the operating room has which responsibility?
a.    Positioning the patient
b.    Assisting with gowning and gloving
c.    Handling surgical instruments to the surgeon
d.    Applying surgical drapes

14.    A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
a.    Leave the medication at the patient’s bedside
b.    Tell the patient to be sure to take the medication. And then leave it at the bedside
c.    Return shortly to the patient’s room and remain there until the patient takes the medication
d.    Wait for the patient to return to bed, and then leave the medication at the bedside

15.    The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
a.    ¼ ml
b.    ½ ml
c.    ¾ ml
d.    1 ¼ ml

16.    The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
a.    39 degrees C
b.    47 degrees C
c.    38.9 degrees C
d.    40.1 degrees C

17.    To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
a.    Red blood cell count
b.    Sputum culture
c.    Total hemoglobin
d.    Arterial blood gas (ABG) analysis

18.    The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
a.    The bell detects high-pitched sounds best
b.    The diaphragm detects high-pitched sounds best
c.    The bell detects thrills best
d.    The diaphragm detects low-pitched sounds best

19.    A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
a.    Within 1 month
b.    Within 3 months
c.    Within 6 months
d.    Within 12 months

20.    Which human element considered by the nurse in charge during assessment can affect drug administration?
a.    The patient’s ability to recover
b.    The patient’s occupational hazards
c.    The patient’s socioeconomic status
d.    The patient’s cognitive abilities

21.    An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
a.    Primary prevention
b.    Secondary prevention
c.    Tertiary prevention
d.    Passive prevention

22.    What does the nurse in charge do when making a surgical bed?
a.    Leaves the bed in the high position when finished
b.    Places the pillow at the head of the bed
c.    Rolls the patient to the far side of the bed
d.    Tucks the top sheet and blanket under the bottom of the bed

23.    The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
a.    2 ml
b.    1 ml
c.    ½ ml
d.    ¼ ml

24.    Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
a.    Prolonged half-life
b.    Poor absorption
c.    Potential for drug dependence
d.    Potential for hepatotoxicity

25.    Which nursing action is essential when providing continuous enteral feeding?
a.    Elevating the head of the bed
b.    Positioning the patient on the left side
c.    Warming the formula before administering it
d.    Hanging a full day’s worth of formula at one time

26.    When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
a.    Top of the tongue
b.    Roof of the mouth
c.    Floor of the mouth
d.    Inside of the cheek

27.    Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
a.    Cleaning from the center outward in a circular motion
b.    Removing the drain before cleaning the skin
c.    Cleaning briskly around the site with alcohol
d.    Wearing sterile gloves and a mask

28.    The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
a.    15 drop per minute
b.    21 drop per minute
c.    32 drop per minute
d.    125 drops per minute

29.    A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
a.    Restlessness
b.    Pale, warm, dry skin
c.    Heart rate of 110 beats/minute
d.    Urine output of 30 ml/hour

30.    Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
a.    Radial
b.    Brachial
c.    Femoral
d.    Carotid

Answers and Rationale

More NCLEX review soon…

1. Answer – D. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use nonirritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. Bathing may be limited but need not be avoided entirely. The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary.

2. Answer – C. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. It improves circulation but does not result in vasoconstriction. The nurse can assess the patient’s condition throughout the bath, regardless of washing technique, and should feel no strain while bathing the patient.

3. Answer – B. Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming. Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep.

4. Answer – C. Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives.

5. Answer – A. Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep.

6. Answer – D. By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. The other choices are valid reasons for using restraints.

7. Answer – D. When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints.

8. Answer – C. Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance.

9. Answer – C. Numbness is typical of the depression stage, when the patient feels a great sense of loss. The anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?”

10. Answer – C. According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured.

11. Answer – C. Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles become weak and atonic, and periods of apnea occur during respiration.

12. Answer – B. The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. The National League of Nursing’s (NLN’s) major function is accrediting nursing education programs in the
United States. The American Medical Association (AMA) is a national organization of physicians. The American Nurses’ Association (ANA) is a national organization of registered nurses.

13. Answer – A. Before instituting isolation precaution, the nurse must first determine the organism’s mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a grown, and gloves when coming in direct contact with the patient. The organism’s Gram-straining characteristics reveal whether the organism is gram-negative or gram-positive, an important criterion in the physician’s choice for drug therapy and the nurse’s development of an effective plan of care. The nurse also needs to know whether the organism is susceptible to antibiotics, but this could take several days to determine; if she waits for the results before instituting isolation precautions, the organism could be transmitted in the meantime. The patient’s susceptibility to the organism has already been established. The nurse would not be instituting isolation precautions for a noninfected patient.

14. Answer – C. Placing the specimen in a sterile container ensures that it will not become contaminated. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth).

15. Answer – D. An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressured steam, is used because it can destroy all forms of microorganisms, including spores.

16. Answer – C. Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should than be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment.

17. Answer – C. Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in swelling and pallor, not erythema, near the insertion site. The patient has no evidence of bleeding.

18. Answer – B. Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication. Shaking the vial vigorously can break down the medication and alter its pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent.

19. Answer – C. When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol before injecting the insulin.

20. Answer – A. 25 gtt/minute

21. Answer – A. 0.5 ml

22. Answer – B. Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure accurate measurements.

23. Answer – C. After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. In this situation, the patient recently ingested medication, so the nurse needs to check for remnants of the medication to help determine whether the patient retained enough of it to be effective. The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an antiemetic.

24. Answer – B. A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine.

25. Answer – B. A new assistant nurse manger should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change. Written assignments allow all staff members to know their own and others responsibilities and serve as a checklist for the manager, enabling her to gauge whether the unit is being run effectively and whether patients are receiving appropriate care. Telling the staff nurses that she is making changes to benefit their performance should occur only after the nurse has made a thorough evaluation. Evaluations are usually done on a yearly basis or as needed.

a. Avoid bathing the patient until the condition is remedied, and notify the physician

b. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear

c. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection

d. Encourage the patient to increase his fluid intake, use nonirritating soap when bathing the patient, and apply lotion to the involved areas

2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:

a. Provides an opportunity for skin assessment

b. Avoids undue strain on the nurse

c. Increases venous blood return

d. Causes vasoconstriction and increases circulation

3. Vivid dreaming occurs in which stage of sleep?

a. Stage I non-REM

b. Rapid eye movement (REM) stage

c. Stage II non-REM

d. Delta stage

4. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:

a. Flurazepam

b. Temazepam

c. Tryptophan

d. Methotrimeprazine

5. Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:

a. Have the patient take a 30- to 60-minute nap in the afternoon

b. Turn on the television in the patient’s room

c. Provide quiet music and interesting reading material

d. Massage the patient’s back with long strokes

6. Restraints can be used for all of the following purposes except to:

a. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters

b. Prevent a patient from falling out of bed or a chair

c. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety

d. Prevent a patient from becoming confused or disoriented

7. Which of the following is the nurse’s legal responsibility when applying restraints?

a. Document the patient’s behavior

b. Document the type of restraint used

c. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others

d. All of the above

8. Kubler-Ross’s five successive stages of death and dying are:

a. Anger, bargaining, denial, depression, acceptance

b. Denial, anger, depression, bargaining, acceptance

c. Denial, anger, bargaining, depression acceptance

d. Bargaining, denial, anger, depression, acceptance

9. A terminally ill patient usually experiences all of the following feelings during the anger stage except:

a. Rage

b. Envy

c. Numbness

d. Resentment

10. Nurses and other health care provides often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

a. Taking psychology courses related to gerontology

b. Reading books and other literature on the subject of thanatology

c. Reflecting on the significance of death

d. Reviewing varying cultural beliefs and practices related to death

11. Which of the following symptoms is the best indicator of imminent death?

a. A weak, slow pulse

b. Increased muscle tone

c. Fixed, dilated pupils

d. Slow, shallow respirations

12. A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:

a. National League for Nursing (NLN)

b. Centers for Disease Control (CDC)

c. American Medical Association (AMA)

d. American Nurses Association (ANA)

13. To institute appropriate isolation precautions, the nurse must first know the:

a. Organism’s mode of transmission

b. Organism’s Gram-staining characteristics

c. Organism’s susceptibility to antibiotics

d. Patient’s susceptibility to the organism

14. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

a. Have the patient place the specimen in a container and enclose the container in a plastic bag

b. Have the patient expectorate the sputum while the nurse holds the container

c. Have the patient expectorate the sputum into a sterile container

d. Offer the patient an antiseptic mouthwash just before he expectorate the sputum

15. An autoclave is used to sterilize hospital supplies because:

a. More articles can be sterilized at a time

b. Steam causes less damage to the materials

c. A lower temperature can be obtained

d. Pressurized steam penetrates the supplies better

16. The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

a. Wash the gloves before removing them

b. Gently pull on the fingers of the gloves when removing them

c. Gently pull just below the cuff and invert the gloves when removing them

d. Remove the gloves and then turn them inside out

17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematons. This usually indicates:

a. Infection

b. Infiltration

c. Phlebitis

d. Bleeding

18. To ensure homogenization when diluting powdered medication in a vial, the nurse should:

a. Shake the vial vigorously

b. Roll the vial gently between the palms

c. Invert the vial and let it stand for 1 minute

d. Do nothing after adding the solution to the vial

19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:

a. Assess the injection site

b. Select the appropriate injection site

c. Check the syringe to verify that the nurse has removed the prescribed insulin dose

d. Clean the injection site in a circular manner with and alcohol sponge

20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?

a. 25 gtt/minute

b. 37 gtt/minute

c. 50 gtt/minute

d. 60 gtt/minute

21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

a. 0.5 ml

b. 0.75 ml

c. 1 ml

d. 2 ml

22. How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

a. Draw up the NPH insulin, then the regular insulin, in the same syringe

b. Draw up the regular insulin, then the NPH insulin, in the same syringe

c. Use two separate syringe

d. Check with the physician

23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

a. Call the physician

b. Remedicate the patient

c. Observe the emesis

d. Explain to the patient that she can do nothing to help him

24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:

a. Trauma has occurred

b. His 24-hour output is adequate

c. He has a urinary tract infection

d. Residual urine remains in the bladder after voiding

25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

a. Writing down all assignments

b. Making changes after evaluating the situation and having discussions with the staff.

c. Telling the staff nurses that she is making changes to benefit their performance

d. Evaluating the clinical performance of each staff nurse in a private conference

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1.      Answer – B. Arthritis is characterized by joint inflammation that is usually accompanied by pain and frequently accompanied by changes in structure. Synovitis is the inflammation of the synovial membrane, typically resulting from a traumatic injury or an aseptic wound. Bursitis is the inflammation of a bursa, typically one located between a bony prominence and a muscle or tendon. Tendinitis is the inflammation of tendon.

2.      Answer – C. Hemoptysis is the expectoration of blood from the respiratory tract. A hemorrhage is abnormal internal or external bleeding. Hematopoiesis is blood cell formation. Hemopexis is blood coagulation.

3.      Answer – B. Ataxia is lack of coordination in performing planned, purposeful movements, typically resulting from a neurologic deficit. Apraxia is the inability to perform purposeful movements even though no neuromuscular deficit exists. Fasciculations are fine twitching movements. Myokymia is a transient, spontaneous movement that occurs in muscle groups after strenuous exercise.

4.      Answer – D. Hypercapnia is an elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2). Hypernatremia is an elevated level of sodium in venous blood (more than 145 mEq/liter). Hypocalcemia is a decreased level of calcium in venous blood (less than 9 mg/dl). Hypoxemia is a reduced level of oxygen in arterial blood (less than 80 mm Hg while breathing room air).

5.      Answer – B. The combining form penia means deficiency, as in thrombocytopenia (deficiency in the number of circulating blood plates). Rrhexis is a combining form meaning rupture, as in enterorrhexis (rupture of the intestine). Plast is a combining form meaning formation, as in rhino-plasty (formation of a nose using plastic surgery). Narco is a combining form meaning stupor, as in narcolepsy (a condition marked by recurrent attacks of drowsiness and sleep).

6.      Answer – B. Fluid volume deficit related to fever is the appropriate nursing diagnosis based on this assessment. Potential for impaired skin integrity states a possible patient response. Potential for fluid volume deficit caused by fever implies a cause-and-effect relationship, which a nursing diagnosis should never do. Altered cardiopulmonary tissue perfusion related to fluid excess is an incorrect diagnosis based on a misinterpretation of the data.

7.      Answer – D. A nursing diagnosis is a statement about a patient’s actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never a part of the nursing diagnosis. An appropriate nursing diagnosis would be ineffective breathing pattern related to chest pain rather than ineffective breathing pattern caused by angina.

8.      Answer – D. A water-soluble lubricant must be applied to the tip of the catheter to decrease friction and the risk of injury to the patient’s nasal mucosa. (If petrolatum or mineral oil were applied to the catheter and then aspirated, the patient could develop a lipoid pneumonia) The distance from the tip of the nose to the tip of the earlobe is the approximate distance from the point of insertion to the oropharynx. Sterile distilled water must be used to humidity the oxygen because oxygen administered by itself is a dry gas that can irritate the mucosa.

9.      Answer – A. Patient safety is the major concern in this situation. According to the International Council of Nurses’ Code for Nurses: “The nurse [should] take appropriate action to safeguard the individual when his or her care is endangered by a co-worker or any other person.” In this case, talking with the head nurse immediately would be the best way to safeguard the patient’s safety. The nurse isn’t necessarily an addict, she may be abusing a prescription medication.

10.  Answer – D. It is the staff nurse’s responsibility to be on time. The nurse manager should not assume a responsibility that belongs to the nurse.

11.  Answer – D. Although Medicare and Medicaid regulations and suggestions made by such groups as the National Kidney Foundation may serve as guidelines, a hospital’s procedure manual details how the nurse should perform her specific duties. A state’s nurse practice act defines the scope of practice within that state, but not the specifics for each area of practice.

12.  Answer – A. The three elements necessary to establishes nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or healing pad to a patient without a physician’s order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.

13.  Answer – B. Therapeutic communication is a two way, deliberative interaction between the patient and nurse in which they establish mutually acceptable, achievable goals of care. Before the patient can feel comfortable discussing his problems, however, and atmosphere of trust and acceptance must be established.

14.  Answer – C. Many variables affect patient nurse communication, including the patient’s cultural beliefs, experiences with hospitalization, age, emotional needs, and problems with speech, hearing, or comprehension. A patient admitted to the hospital for the first time for a scheduled cesarean section is probably anxious, but she had time to plan for the procedure, does not bring negative experiences from previous hospitalizations, and in most cases looks forward to the birth.

15.  Answer – D. Therapeutic communication is a fundamental component at all phases of the nursing process. In the planning phase, it allows the patient and nurse to formulate mutually acceptable and patient-oriented goals, which are the basis for developing an individualized care plan. In the implementation phase, effective communication is necessary for teaching the patient, motivating him to achieve goals, and assessing patient outcomes. Finally, in the evaluation phase, it is required to determine how well the patient has responded to interventions.

16.  Answer – C. Objective data are those which can be measured, like glucose levels. A complaint of polydipsia is subjective information obtained from the patient.

17.  Answer – D. Peristalsis is the muscular, rhythmic movement in the bowel wall that pushes food along the digestive tract distally. Increased bowel motility is indicated by rapid, high-pitched, hyperactive bowel sounds. Decreased bowel sounds, caused by decreased bowel motility, can be the initial sign of paralytic ileus (adynamic intestinal obstruction resulting from the lack of peristalsis), a common occurrence following abdominal surgery.

18.  Answer – D. The use of a tilt table for weight-beating exercises, parenteral nutrition, and vitamin therapy are not independent nursing interventions because they require a physician’s order. Unless specifically contraindicated, the independent nursing interventions listed in A, B, and C may be part of the nursing care plan for an immobilized patient.

19.  Answer – A. Independent nursing interventions for a patient with pressure ulcers commonly include changing his position several times each day to avoid pressure to any part of his body, especially the involved area. Drying agents, which are prescribed by a physician, are contraindicated because wounds need moisture to heal. Whirlpool therapy and chemical debridement must be prescribed, and surgical debridement is done by the physician.

20.  Answer – D. All of the choices will help the nurse determine the extent of the problem. For example, asking how the patient felt about her body before hospitalization will help the nurse determine whether the disturbed body image is a crisis brought on by the weight gain or a long-standing problem. Asking what the change means to her will reveal whether she feels she has control over what is happening or believes the change is permanent. Body image is also related to how we think we compare to others or whether others find us attractive.

21.  Answer – C. Because aldosterone regulates the body’s sodium and potassium levels, it acts as an adaptive mechanism in maintaining blood volume and conserving water. Supplemental potassium usually is given to a patient with a low serum potassium level or one who is receiving a diuretic or other medication – such as digoxin – that has a mild diuretic effect. A low-sodium diet is usually prescribed for a patient with a high serum sodium level, as in congestive heart failure (CHF), hypertension, or prolonged episodes of edema. Diuresis is increased naturally when a healthy patient increases his intake of fluids, especially those containing caffeine. Patients receiving diuretics also experience increased diuresis.

22.  Answer – D. Interviewing the patient – in both a structured and an unstructured format – is an important part of the initial nursing assessment. The structured format uses questions that require a yea-or-no answer to help the nurse obtain information; the unstructured format uses open-ended questions that allow the patient to express himself more fully. The interview helps the nurse and patient identify the stressors and develop appropriate outcomes.

23.  Answer – C. Calculating the difference in weight between a dry pad and a urine saturated pad using conversion calibration will provide an accurate measure of urine output. For example, if the difference between the dry pad and the urine-saturated pad is 200 g, the urine output would be 200 ml (1g = 1 ml). The other methods will provide only an estimate of urine output.

24.  Answer – C. Disturbances in self-concept may manifest themselves as signs and symptoms of depression, such as changes in sleep patterns, eating habits, and energy levels. The other nursing diagnoses are not supported by the given situation.

25.  Answer – C. An appropriate nursing diagnosis for a patient with excessively dry skin is Impaired skin integrity (actual not potential) – in this case, related to dehydration because the patient complains of thirst. Altered circulation is not usually an etiologic factor for dry skin.

a. Synovitis

b. Arthritis

c. Bursitis

d. Tendinitis

2. Which term refers to the expectoration of blood from the respiratory tract?

a. A hemorrhage

b. Hematopoiesis

c. Hemoptysis

d. Hemopexis

3. Which term describes lack of coordination in performing planned, purposeful movements, resulting from a neurologic deficit?

a. Apraxia

b. Ataxia

c. Fasciculation

d. Myokymia

4. An elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2) indicates that the patient has:

a. Hypernatremia

b. Hypocalcemia

c. Hypoxemia

d. Hypercapnia

5. The latest laboratory values indicate that the patient has thrombocytopenia. The combining form penia means:

a. Rupture

b. Deficiency

c. Formation

d. Stupor

6. A patient is admitted to the hospital with a urine specific gravity of 1.030, a temperature of 102°F (38.9° C), and flushed, dry skin. Based on these data, the nurse writes which of the following nursing diagnoses?

a. Potential for impaired skin integrity

b. Fluid volume deficit related to fever

c. Potential for fluid volume deficit caused by fever

d. Altered cardiopulmonary tissue perfusion related to fluid excess

7. The guidelines for writing an appropriate nursing diagnosis include all of the following except:

a. State the diagnosis in terms of a problem, not a need

b. Use nursing terminology to describe the patient’s response

c. Use statements that assist in planning independent nursing interventions

d. Use medical terminology to describe the probable cause of the patient’s response

8. Based on a physician’s order for oxygen by nasal catheter at 3 liters/ minute, an appropriate nursing order would be:

a. Cover the tip of the catheter with a water-soluble lubricant before insertion.

b. Measure the length of the catheter from the tip of the patient’s nose to the tip of the earlobe before insertion

c. Add sterile distilled water to the humidification container, as needed

d. All of the above

9. A nurse observes a dazed and apparently confused co-worker taking two diazepam (Valium) tablets by mouth as the co-worker is about to pour medications. What should the nurse do?

a. Call the head nurse immediately before the co-worker pours and administers the medications

b. Pour the medications for the co-worker while she goes for a cup of coffee

c. Report the co-worker to hospital security because she may be addicted to drugs

d. Watch the co-worker closely and report the incident to the head nurse at the end of the day.

10. A nurse manager notices that one of the staff nurses is always 15 to 20 minutes late. When the nurse manager discusses the problem with her, the nurse says that she has been late because her son’s nursery school does not open until 7 am. The nurse manager should respond by telling her to:

a. Ask one of the night nurses to cover for her

b. See if a neighbor can take the child to school

c. Find out if other schools open earlier

d. Find some way to solve the problem and be on time

11. A nurse has just moved to a new state, where she has accepted employment in a hospital-based hemodialysis unit. She needs information about her specific duties in caring for hemodialysis patients. She will find this information in:

a. Policy statements set by the National Kidney Foundation

b. The state’s nurse practice act

c. Medicare and Medicaid regulations

d. The hospital’s procedure manual

12. Which of the following is an example of nursing malpractice?

a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.

b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping

c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus

d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor

13. Therapeutic communication is a significant aspect of patient care. Which of the following statements most clearly defines this concept?

a. Therapeutic communication conveys feelings of warmth, acceptance, and empathy from the nurse to the patient in a nonjudgmental atmosphere

b. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals

c. Therapeutic communication is the assessment component of the nursing process, in which the nurse gathers health history information from the patient’s perspective

d. Therapeutic communication is an interactional process in which the nurse purposefully reviews and assesses the conversation and its potential outcomes

14. Many factors can become barriers to communication. In which of the following situations would communication least likely be hindered?

a. Mr. S., a 30-year-old Vietnamese immigrant, is admitted to the hospital with a fractured tibia; he speaks limited English

b. Ms. M., age 58 and unmarried, is admitted to the hospital for breast surgery

c. Mrs. R, age 26, is admitted to the hospital for a scheduled cesarean section; this is her first admission

d. Mr. G., age 78, arrives at the hospital by ambulance after suffering a stroke at home

15. The assessment component of the nursing process requires effective communication to elicit a complete, relevant history from the patient and to identify patient problems. What role does communication play in the other areas of the nursing process?

a. In the planning phase, effective therapeutic communication helps to establish nursing care priorities and patient-oriented goals

b. During the implementation phase, communication skills allow the nurse to assess the patient’s response to planned interventions

c. During the evaluation phase, effective communication allows the nurse to find out from the patient if he is responding to treatment or if changes in treatment are necessary

d. All of the above

16. All of the following would be considered objective assessment data for a patient admitted with diabetes mellitus except:

a. + 2 urine glucose level; negative urine acetone level

b. Chemstrip reading of 240 mg/dl

c. Patient complaints of polydipsia

d. Serum glucose level of 263 mg/dl

17. Which of the following statements about bowel sounds is accurate?

a. Peristalsis causes bowel sounds

b. Rapid, high-pitched, hyperactive bowel sounds indicate increased peristalsis

c. Decreased bowel sounds can be a symptom of paralytic ileus

d. All of the above

18. Independent nursing intervention commonly used for immobilized patients include all of the following except:

a. Active or passive ROM exercises, body repositioning, and activities of daily living (ADLs) as tolerated

b. Deep-breathing and coughing exercises with change of position every 2 hours

c. Diaphragmatic and abdominal breathing exercises and increased hydration

d. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy

19. Independent nursing interventions commonly used for patients with pressure ulcers include:

a. Changing the patient’s position regularly to minimize pressure

b. Applying a drying agent such as an antacid to decrease moisture at the ulcer site

c. Debriding the ulcer to remove necrotic tissue, which can impede healing

d. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated

20. A female patient has gained 24 lb after being admitted to the hospital. “I’m such a horse; I just can’t stand myself like this,” she tells the nurse. After assessing the patient, the nurse writes the following nursing diagnosis: Body image disturbance. To arrive at this diagnosis, the nurse should include which of the following assessment findings?

a. The patient’s perception of her body before the hospitalization and weight gain

b. The significance the patient places on these changes

c. The patient’s feelings about her body

d. All of the above

21. Stressors cause the release of the mineralocorticoid aldosterone, which regulates sodium absorption and potassium excretion in the renal tubules, resulting in:

a. The need for supplemental potassium

b. The need for a low-sodium (500-mg) diet

c. The conservation of water and maintenance of blood volume

d. Increased diuresis

22. In planning the care of a patient who is exposed to multiple stressors such as separation from loved ones, anxiety about impending surgery, and concern about potential complications or death, the nurse must:

a. Use both a structured and an unstructured format when interviewing the patient

b. Know the stressors affecting the patient

c. Develop the expected outcomes for each nursing diagnosis written for this patient

d. All of the above

23. An accurate method of calculating the daily urine output of an incontinent patient wearing pads or diapers is to:

a. Estimate the urine output

b. Count the number of urine saturated pads

c. Weigh a dry pad and each urine saturated pad and use a conversion calibration to calculate the urine output

d. Weigh all the urine-saturated pads together and use a conversion calibration to calculate the urine output

24. A fashion model is admitted via the emergency room with facial and chest burns. Her hospital stay includes 10 days in the intensive care unit and 5 days on the regular hospital unit. The patient has not been eating or sleeping and refuses to perform her activities of daily living (ADLs). She refuses to work with speech and physical therapists. Which of the following nursing diagnoses might appears on the patient’s current care plan?

a. Potential for noncompliance: Self-harm related to disturbed body image

b. Self-care deficit related to knowledge deficit and disturbed body image

c. Disturbance in self-concept: Personal identifying related to self-esteem

d. Disturbance in self-concept related to altered thought process

25. White the nurse is providing a patient’s personal hygiene, she observes that his skin is excessively dry. During this procedure the patient tells her that he is very thirsty. An appropriate nursing diagnosis would be:

a. Potential for impaired skin integrity related to altered gland function

b. Potential for impaired skin integrity related to dehydration

c. Impaired skin integrity relate to dehydration

d. Impaired skin integrity related to altered circulation

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