NURSING
A. 30 seconds
B. 1 minute
PNLE I for Foundation of C. 2 minute
D. 3 minutes
Answer: A. Depending on the degree of
Nursing exposure to pathogens, hand washing may last
1. Which element in the circular chain of infection from 10 seconds to 4 minutes. After routine
can be eliminated by preserving skin integrity? patient contact, hand washing for 30 seconds
effectively minimizes the risk of
A. Host pathogen transmission.
B. Reservoir
C. Mode of transmission 6. Which of the following procedures always
D. Portal of entry requires surgical asepsis?
Answer: D. In the circular chain of infection, A. Vaginal instillation of conjugated estrogen
pathogens must be able to leave their reservoir B. Urinary catheterization
and be transmitted to a susceptible host through C. Nasogastric tube insertion
a portal of entry, such as broken skin. D. Colostomy irrigation
2. Which of the following will probably result in a Answer: B. The urinary system is normally free
break in sterile technique for respiratory of microorganisms except at the urinary meatus.
isolation? Any procedure that involves entering this system
must use surgically aseptic measures to
A. Opening the patient’s window to the maintain a bacteria-free state
outside environment
B. Turning on the patient’s room ventilator 7. Sterile technique is used whenever:
C. Opening the door of the patient’s
room leading into the hospital corridor A. Strict isolation is required
D. Failing to wear gloves when administering B. Terminal disinfection is performed
a bed bath C. Invasive procedures are performed
D. Protective isolation is necessary
Answer: C. Respiratory isolation, like strict
isolation, requires that the door to the door Answer: C. All invasive procedures, including
patient’s room remain closed. However, the surgery, catheter insertion, and administration
patient’s room should be well ventilated, so of parenteral therapy, require sterile technique
opening the window or turning on the ventricular to maintain a sterile environment. All equipment
is desirable. The nurse does not need to wear must be sterile, and the nurse and the physician
gloves for respiratory isolation, but good hand must wear sterile gloves and maintain surgical
washing is important for all types of isolation asepsis. In the operating room, the nurse and
physician are required to wear sterile gowns,
3. Which of the following patients is at greater gloves, masks, hair covers, and shoe covers for
risk for contracting an infection? all invasive procedures. Strict isolation requires
the use of clean gloves, masks, gowns and
A. A patient with leukopenia equipment to prevent the transmission of highly
B. A patient receiving broad-spectrum communicable diseases by contact or by
antibiotics airborne routes. Terminal disinfection is
C. A postoperative patient who has the disinfection of all contaminated supplies and
undergone orthopedic surgery equipment after a patient has been discharged
D. A newly diagnosed diabetic patient to prepare them for reuse by another patient.
The purpose of protective (reverse) isolation is
Answer: A. Leukopenia is a decreased number of to prevent a person with seriously impaired
leukocytes (white blood cells), which are resistance from coming into contact who
important in resisting infection. None of the potentially pathogenic organisms.
other situations would put the patient at risk for
contracting an infection; taking 8. Which of the following constitutes a break in
broadspectrum antibiotics might actually reduce sterile technique while preparing a sterile field for
the infection risk. a dressing change?
4. Effective hand washing requires the use of: A. Using sterile forceps, rather than sterile
gloves, to handle a sterile item
A. Soap or detergent to promote B. Touching the outside wrapper of sterilized
emulsification material without sterile gloves
B. Hot water to destroy bacteria C. Placing a sterile object on the edge of
C. A disinfectant to increase surface tension the sterile field
D. All of the above D. Pouring out a small amount of solution (15
to 30 ml) before pouring the solution into a
Answer: A. Soaps and detergents are used to sterile container
help remove bacteria because of their ability to
, when administering an I.M. injection. Enteric
9. A natural body defense that plays an active precautions prevent the transfer of pathogens
role in preventing infection is: via feces.
A. Yawning 13.All of the following measures are
B. Body hair recommended to prevent pressure ulcers except:
C. Hiccupping
D. Rapid eye movements A. Massaging the reddened are with
lotion
Answer: B. Hair on or within body areas, such as B. Using a water or air mattress
the nose, traps and holds particles that contain C. Adhering to a schedule for positioning and
microorganisms. Yawning and hiccupping do turning
not prevent microorganisms from entering or D. Providing meticulous skin care
leaving the body. Rapid eye movement marks
the stage of sleep during which dreaming Answer: A. Nurses and other health care
occurs. professionals previously believed that massaging
a reddened area with lotion would promote
10. All of the following statement are true about venous return and reduce edema to the area.
donning sterile gloves except: However, research has shown that massage only
increases the likelihood of cellular ischemia and
A. The first glove should be picked up by necrosis to the area
grasping the inside of the cuff. 14.Which of the following blood tests should be
B. The second glove should be picked up by performed before a blood transfusion?
inserting the gloved fingers under the cuff
outside the glove. A. Prothrombin and coagulation time
C. The gloves should be adjusted by sliding B. Blood typing and cross-matching
the gloved fingers under the sterile cuff and C. Bleeding and clotting time
pulling the glove over the wrist D. Complete blood count (CBC) and
D. The inside of the glove is considered electrolyte levels.
sterile Answer: B. Before a blood transfusion is
Answer: D. The inside of the glove is always performed, the blood of the donor and recipient
considered to be clean, but not sterile. must be checked for compatibility. This is done
by blood typing (a test that determines a
11.When removing a contaminated gown, the person’s blood type) and cross-matching
nurse should be careful that the first thing she (a procedure that determines the compatibility
touches is the: of the donor’s and recipient’s blood after the
blood types has been matched). If the blood
A. Waist tie and neck tie at the back of specimens are incompatible, hemolysis and
the gown antigen-antibody reactions will occur
B. Waist tie in front of the gown
C. Cuffs of the gown 15.The primary purpose of a platelet count is to
D. Inside of the gown evaluate the:
Answer: A. The back of the gown is considered A. Potential for clot formation
clean, the front is contaminated. So, after B. Potential for bleeding
removing gloves and washing hands, the nurse C. Presence of an antigen-antibody response
should untie the back of the gown; slowly move D. Presence of cardiac enzymes
backward away from the gown, holding
the inside of the gown and keeping the edges off Answer: A. Platelets are disk-shaped cells that
the floor; turn and fold the gown inside out; are essential for blood coagulation. A platelet
discard it in a contaminated linen container; count determines the number of thrombocytes in
then wash her hands again. blood available for promoting hemostasis and
assisting with blood coagulation after injury. It
12.Which of the following nursing interventions is also is used to evaluate the patient’s potential for
considered the most effective form or universal bleeding; however, this is not its primary
precautions? purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or less
A. Cap all used needles before removing indicates a potential for bleeding; count of less
them from their syringes than 20,000/mm3 is associated with
B. Discard all used uncapped needles spontaneous bleeding.
and syringes in an impenetrable
protective container 16.Which of the following white blood cell (WBC)
C. Wear gloves when administering IM counts clearly indicates leukocytosis?
injections
D. Follow enteric precautions A. 4,500/mm³
B. 7,000/mm³
Answer: B. According to the Centers for Disease C. 10,000/mm³
Control (CDC), blood-to-blood contact occurs D. 25,000/mm³
most commonly when a health care worker
Answer: D. Leukocytosis is any transient increase
, Answer: A. Initial sensitivity to penicillin is
17. After 5 days of diuretic therapy with 20mg of commonly manifested by a skin rash, even in
furosemide (Lasix) daily, a patient begins to individuals who have not been allergic to it
exhibit fatigue, muscle cramping and muscle previously. Because of the danger of anaphylactic
weakness. These symptoms probably indicate shock, he nurse should withhold the drug
that the patient is experiencing: and notify the physician, who may choose to
substitute another drug. Administering an
A. Hypokalemia antihistamine is a dependent nursing intervention
B. Hyperkalemia that requires a written physician’s order. Although
C. Anorexia applying corn starch to the rash may relieve
D. Dysphagia discomfort, it is not the nurse’s top priority in
such a potentially life-threatening situation.
Answer: A. Fatigue, muscle cramping, and muscle
weaknesses are symptoms of hypokalemia (an 21.All of the following nursing interventions are
inadequate potassium level), which is a potential correct when using the Ztrack method of drug
side effect of diuretic therapy. The physician injection except:
usually orders supplemental potassium to
prevent hypokalemia in patients receiving A. Prepare the injection site with alcohol
diuretics. Anorexia is another symptom of B. Use a needle that’s a least 1” long
hypokalemia. Dysphagia means C. Aspirate for blood before injection
difficulty swallowing. D. Rub the site vigorously after the
injection to promote absorption
18.Which of the following statements about chest
X-ray is false? Answer: D. The Z-track method is an I.M.
injection technique in which the patient’s skin is
A. No contradictions exist for this test pulled in such a way that the needle track is
B. Before the procedure, the patient should sealed off after the injection. This procedure
remove all jewelry, metallic objects, and seals medication deep into the muscle,
buttons above the waist thereby minimizing skin staining and irritation.
C. A signed consent is not required Rubbing the injection site is contraindicated
D. Eating, drinking, and medications are because it may cause the medication to
allowed before this test extravasate into the skin
Answer: A. Pregnancy or suspected pregnancy is 22.The correct method for determining the vastus
the only contraindication for a chest X-ray. lateralis site for I.M. injection is to:
However, if a chest X-ray is necessary, the
patient can wear a lead apron to protect the A. Locate the upper aspect of the upper
pelvic region from radiation. Jewelry, outer quadrant of the buttock about 5 to 8
metallic objects, and buttons would interfere with cm below the iliac crest
the X-ray and thus should not be worn above the B. Palpate the lower edge of the acromion
waist. A signed consent is not required because a process and the midpoint lateral aspect of
chest X-ray is not an invasive examination. the arm
Eating, drinking and medications are allowed C. Palpate a 1” circular area anterior to the
because the X-ray is of the chest, not the umbilicus
abdominal region. D. Divide the area between the greater
femoral trochanter and the lateral femoral
19.The most appropriate time for the nurse to condyle into thirds, and select the middle
obtain a sputum specimen for culture is: third on the anterior of the thigh
A. Early in the morning Answer: D. The vastus lateralis, a long, thick
B. After the patient eats a light breakfast muscle that extends the full length of the thigh, is
C. After aerosol therapy viewed by many clinicians as the site of choice
D. After chest physiotherapy for I.M. injections because it has relatively few
major nerves and blood vessels. The middle third
Answer: A. Obtaining a sputum specimen early in of the muscle is recommended as the injection
this morning ensures an adequate supply of site. The patient can be in a supine or sitting
bacteria for culturing and decreases the risk position for an injection into this site.
of contamination from food or medication.
20.A patient with no known allergies is to receive 23.The mid-deltoid injection site is seldom used
penicillin every 6 hours. When administering the for I.M. injections because it:
medication, the nurse observes a fine rash on the
A. Can accommodate only 1 ml or less of
patient’s skin. The most appropriate nursing medication
action would be to: B. Bruises too easily
C. Can be used only when the patient is lying
A. Withhold the moderation and notify down
the physician D. Does not readily parenteral medication
B. Administer the medication and notify the
, 29.Which of the following is a sign or symptom of
24.The appropriate needle size for insulin a hemolytic reaction to blood transfusion?
injection is:
A. Hemoglobinuria
A. 18G, 1 ½” long B. Chest pain
B. 22G, 1” long C. Urticaria
C. 22G, 1 ½” long D. Distended neck veins
D. 25G, 5/8” long
Answer: A. Hemoglobinuria, the abnormal
Answer: D. A 25G, 5/8” needle is the presence of hemoglobin in the urine, indicates a
recommended size for insulin injection because hemolytic reaction (incompatibility of the donor’s
insulin is administered by the subcutaneous and recipient’s blood). In this reaction, antibodies
route. An 18G, 1 ½” needle is usually used for in the recipient’s plasma combine rapidly with
I.M. injections in children, typically in the donor RBC’s; the cells are hemolyzed in
vastus lateralis. A 22G, 1 ½” needle is usually either circulatory or reticuloendothelial system.
used for adult I.M. injections, which are typically Hemolysis occurs more rapidly in ABO
administered in the vastus lateralis or incompatibilities than in Rh incompatibilities.
ventrogluteal site. Chest pain and urticaria may be symptoms of
impending anaphylaxis. Distended neck veins are
25.The appropriate needle gauge for intradermal an indication of hypervolemia.
injection is:
30.Which of the following conditions may require
A. 20G fluid restriction?
B. 22G
C. 25G A. Fever
D. 26G B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
Answer: D. Because an intradermal injection does D. Dehydration
not penetrate deeply into the skin, a small-bore
25G needle is recommended. This type of Answer: C. In real failure, the kidney loses their
injection is used primarily to administer antigens ability to effectively eliminate wastes and fluids.
to evaluate reactions for allergy or sensitivity Because of this, limiting the patient’s intake of
studies. A 20G needle is usually used for I.M. oral and I.V. fluids may be necessary. Fever,
injections of oilbased medications; a 22G needle chronic obstructive pulmonary disease, and
for I.M. injections; and a 25G needle, for I.M. dehydration are conditions for which fluids should
injections; and a 25G needle, for subcutaneous be encouraged.
insulin injections.
31.All of the following are common signs and
26.Parenteral penicillin can be administered as symptoms of phlebitis except:
an:
A. Pain or discomfort at the IV insertion site
A. IM injection or an IV solution B. Edema and warmth at the IV insertion site
B. IV or an intradermal injection C. A red streak exiting the IV insertion site
C. Intradermal or subcutaneous injection D. Frank bleeding at the insertion site
D. IM or a subcutaneous injection
Answer: D. Phlebitis, the inflammation of a vein,
Answer: A. Parenteral penicillin can be can be caused by chemical irritants (I.V. solutions
administered I.M. or added to a solution and or medications), mechanical irritants (the needle
given I.V. It cannot be administered or catheter used during venipuncture or
subcutaneously or intradermally. cannulation), or a localized allergic reaction to the
needle or catheter. Signs and symptoms of
27.The physician orders gr 10 of aspirin for a phlebitis include pain or discomfort, edema and
patient. The equivalent dose in milligrams is: heat at the I.V. insertion site, and a red streak
going up the arm or leg from the I.V. insertion
A. 0.6 mg site.
B. 10 mg
C. 60 mg 32.The best way of determining whether a patient
D. 600 mg has learned to instill ear medication properly is
for the nurse to:
Answer: D. gr 10 x 60mg/gr 1 = 600 mg
A. Ask the patient if he/she has used ear
28.The physician orders an IV solution of dextrose drops before
5% in water at 100ml/hour. What would the flow B. Have the patient repeat the nurse’s
rate be if the drop factor is 15 gtt = 1 ml? instructions using her own words
C. Demonstrate the procedure to the patient
A. 5 gtt/minute and encourage to ask questions
B. 13 gtt/minute D. Ask the patient to demonstrate the
C. 25 gtt/minute procedure
D. 50 gtt/minute
A. 30 seconds
B. 1 minute
PNLE I for Foundation of C. 2 minute
D. 3 minutes
Answer: A. Depending on the degree of
Nursing exposure to pathogens, hand washing may last
1. Which element in the circular chain of infection from 10 seconds to 4 minutes. After routine
can be eliminated by preserving skin integrity? patient contact, hand washing for 30 seconds
effectively minimizes the risk of
A. Host pathogen transmission.
B. Reservoir
C. Mode of transmission 6. Which of the following procedures always
D. Portal of entry requires surgical asepsis?
Answer: D. In the circular chain of infection, A. Vaginal instillation of conjugated estrogen
pathogens must be able to leave their reservoir B. Urinary catheterization
and be transmitted to a susceptible host through C. Nasogastric tube insertion
a portal of entry, such as broken skin. D. Colostomy irrigation
2. Which of the following will probably result in a Answer: B. The urinary system is normally free
break in sterile technique for respiratory of microorganisms except at the urinary meatus.
isolation? Any procedure that involves entering this system
must use surgically aseptic measures to
A. Opening the patient’s window to the maintain a bacteria-free state
outside environment
B. Turning on the patient’s room ventilator 7. Sterile technique is used whenever:
C. Opening the door of the patient’s
room leading into the hospital corridor A. Strict isolation is required
D. Failing to wear gloves when administering B. Terminal disinfection is performed
a bed bath C. Invasive procedures are performed
D. Protective isolation is necessary
Answer: C. Respiratory isolation, like strict
isolation, requires that the door to the door Answer: C. All invasive procedures, including
patient’s room remain closed. However, the surgery, catheter insertion, and administration
patient’s room should be well ventilated, so of parenteral therapy, require sterile technique
opening the window or turning on the ventricular to maintain a sterile environment. All equipment
is desirable. The nurse does not need to wear must be sterile, and the nurse and the physician
gloves for respiratory isolation, but good hand must wear sterile gloves and maintain surgical
washing is important for all types of isolation asepsis. In the operating room, the nurse and
physician are required to wear sterile gowns,
3. Which of the following patients is at greater gloves, masks, hair covers, and shoe covers for
risk for contracting an infection? all invasive procedures. Strict isolation requires
the use of clean gloves, masks, gowns and
A. A patient with leukopenia equipment to prevent the transmission of highly
B. A patient receiving broad-spectrum communicable diseases by contact or by
antibiotics airborne routes. Terminal disinfection is
C. A postoperative patient who has the disinfection of all contaminated supplies and
undergone orthopedic surgery equipment after a patient has been discharged
D. A newly diagnosed diabetic patient to prepare them for reuse by another patient.
The purpose of protective (reverse) isolation is
Answer: A. Leukopenia is a decreased number of to prevent a person with seriously impaired
leukocytes (white blood cells), which are resistance from coming into contact who
important in resisting infection. None of the potentially pathogenic organisms.
other situations would put the patient at risk for
contracting an infection; taking 8. Which of the following constitutes a break in
broadspectrum antibiotics might actually reduce sterile technique while preparing a sterile field for
the infection risk. a dressing change?
4. Effective hand washing requires the use of: A. Using sterile forceps, rather than sterile
gloves, to handle a sterile item
A. Soap or detergent to promote B. Touching the outside wrapper of sterilized
emulsification material without sterile gloves
B. Hot water to destroy bacteria C. Placing a sterile object on the edge of
C. A disinfectant to increase surface tension the sterile field
D. All of the above D. Pouring out a small amount of solution (15
to 30 ml) before pouring the solution into a
Answer: A. Soaps and detergents are used to sterile container
help remove bacteria because of their ability to
, when administering an I.M. injection. Enteric
9. A natural body defense that plays an active precautions prevent the transfer of pathogens
role in preventing infection is: via feces.
A. Yawning 13.All of the following measures are
B. Body hair recommended to prevent pressure ulcers except:
C. Hiccupping
D. Rapid eye movements A. Massaging the reddened are with
lotion
Answer: B. Hair on or within body areas, such as B. Using a water or air mattress
the nose, traps and holds particles that contain C. Adhering to a schedule for positioning and
microorganisms. Yawning and hiccupping do turning
not prevent microorganisms from entering or D. Providing meticulous skin care
leaving the body. Rapid eye movement marks
the stage of sleep during which dreaming Answer: A. Nurses and other health care
occurs. professionals previously believed that massaging
a reddened area with lotion would promote
10. All of the following statement are true about venous return and reduce edema to the area.
donning sterile gloves except: However, research has shown that massage only
increases the likelihood of cellular ischemia and
A. The first glove should be picked up by necrosis to the area
grasping the inside of the cuff. 14.Which of the following blood tests should be
B. The second glove should be picked up by performed before a blood transfusion?
inserting the gloved fingers under the cuff
outside the glove. A. Prothrombin and coagulation time
C. The gloves should be adjusted by sliding B. Blood typing and cross-matching
the gloved fingers under the sterile cuff and C. Bleeding and clotting time
pulling the glove over the wrist D. Complete blood count (CBC) and
D. The inside of the glove is considered electrolyte levels.
sterile Answer: B. Before a blood transfusion is
Answer: D. The inside of the glove is always performed, the blood of the donor and recipient
considered to be clean, but not sterile. must be checked for compatibility. This is done
by blood typing (a test that determines a
11.When removing a contaminated gown, the person’s blood type) and cross-matching
nurse should be careful that the first thing she (a procedure that determines the compatibility
touches is the: of the donor’s and recipient’s blood after the
blood types has been matched). If the blood
A. Waist tie and neck tie at the back of specimens are incompatible, hemolysis and
the gown antigen-antibody reactions will occur
B. Waist tie in front of the gown
C. Cuffs of the gown 15.The primary purpose of a platelet count is to
D. Inside of the gown evaluate the:
Answer: A. The back of the gown is considered A. Potential for clot formation
clean, the front is contaminated. So, after B. Potential for bleeding
removing gloves and washing hands, the nurse C. Presence of an antigen-antibody response
should untie the back of the gown; slowly move D. Presence of cardiac enzymes
backward away from the gown, holding
the inside of the gown and keeping the edges off Answer: A. Platelets are disk-shaped cells that
the floor; turn and fold the gown inside out; are essential for blood coagulation. A platelet
discard it in a contaminated linen container; count determines the number of thrombocytes in
then wash her hands again. blood available for promoting hemostasis and
assisting with blood coagulation after injury. It
12.Which of the following nursing interventions is also is used to evaluate the patient’s potential for
considered the most effective form or universal bleeding; however, this is not its primary
precautions? purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or less
A. Cap all used needles before removing indicates a potential for bleeding; count of less
them from their syringes than 20,000/mm3 is associated with
B. Discard all used uncapped needles spontaneous bleeding.
and syringes in an impenetrable
protective container 16.Which of the following white blood cell (WBC)
C. Wear gloves when administering IM counts clearly indicates leukocytosis?
injections
D. Follow enteric precautions A. 4,500/mm³
B. 7,000/mm³
Answer: B. According to the Centers for Disease C. 10,000/mm³
Control (CDC), blood-to-blood contact occurs D. 25,000/mm³
most commonly when a health care worker
Answer: D. Leukocytosis is any transient increase
, Answer: A. Initial sensitivity to penicillin is
17. After 5 days of diuretic therapy with 20mg of commonly manifested by a skin rash, even in
furosemide (Lasix) daily, a patient begins to individuals who have not been allergic to it
exhibit fatigue, muscle cramping and muscle previously. Because of the danger of anaphylactic
weakness. These symptoms probably indicate shock, he nurse should withhold the drug
that the patient is experiencing: and notify the physician, who may choose to
substitute another drug. Administering an
A. Hypokalemia antihistamine is a dependent nursing intervention
B. Hyperkalemia that requires a written physician’s order. Although
C. Anorexia applying corn starch to the rash may relieve
D. Dysphagia discomfort, it is not the nurse’s top priority in
such a potentially life-threatening situation.
Answer: A. Fatigue, muscle cramping, and muscle
weaknesses are symptoms of hypokalemia (an 21.All of the following nursing interventions are
inadequate potassium level), which is a potential correct when using the Ztrack method of drug
side effect of diuretic therapy. The physician injection except:
usually orders supplemental potassium to
prevent hypokalemia in patients receiving A. Prepare the injection site with alcohol
diuretics. Anorexia is another symptom of B. Use a needle that’s a least 1” long
hypokalemia. Dysphagia means C. Aspirate for blood before injection
difficulty swallowing. D. Rub the site vigorously after the
injection to promote absorption
18.Which of the following statements about chest
X-ray is false? Answer: D. The Z-track method is an I.M.
injection technique in which the patient’s skin is
A. No contradictions exist for this test pulled in such a way that the needle track is
B. Before the procedure, the patient should sealed off after the injection. This procedure
remove all jewelry, metallic objects, and seals medication deep into the muscle,
buttons above the waist thereby minimizing skin staining and irritation.
C. A signed consent is not required Rubbing the injection site is contraindicated
D. Eating, drinking, and medications are because it may cause the medication to
allowed before this test extravasate into the skin
Answer: A. Pregnancy or suspected pregnancy is 22.The correct method for determining the vastus
the only contraindication for a chest X-ray. lateralis site for I.M. injection is to:
However, if a chest X-ray is necessary, the
patient can wear a lead apron to protect the A. Locate the upper aspect of the upper
pelvic region from radiation. Jewelry, outer quadrant of the buttock about 5 to 8
metallic objects, and buttons would interfere with cm below the iliac crest
the X-ray and thus should not be worn above the B. Palpate the lower edge of the acromion
waist. A signed consent is not required because a process and the midpoint lateral aspect of
chest X-ray is not an invasive examination. the arm
Eating, drinking and medications are allowed C. Palpate a 1” circular area anterior to the
because the X-ray is of the chest, not the umbilicus
abdominal region. D. Divide the area between the greater
femoral trochanter and the lateral femoral
19.The most appropriate time for the nurse to condyle into thirds, and select the middle
obtain a sputum specimen for culture is: third on the anterior of the thigh
A. Early in the morning Answer: D. The vastus lateralis, a long, thick
B. After the patient eats a light breakfast muscle that extends the full length of the thigh, is
C. After aerosol therapy viewed by many clinicians as the site of choice
D. After chest physiotherapy for I.M. injections because it has relatively few
major nerves and blood vessels. The middle third
Answer: A. Obtaining a sputum specimen early in of the muscle is recommended as the injection
this morning ensures an adequate supply of site. The patient can be in a supine or sitting
bacteria for culturing and decreases the risk position for an injection into this site.
of contamination from food or medication.
20.A patient with no known allergies is to receive 23.The mid-deltoid injection site is seldom used
penicillin every 6 hours. When administering the for I.M. injections because it:
medication, the nurse observes a fine rash on the
A. Can accommodate only 1 ml or less of
patient’s skin. The most appropriate nursing medication
action would be to: B. Bruises too easily
C. Can be used only when the patient is lying
A. Withhold the moderation and notify down
the physician D. Does not readily parenteral medication
B. Administer the medication and notify the
, 29.Which of the following is a sign or symptom of
24.The appropriate needle size for insulin a hemolytic reaction to blood transfusion?
injection is:
A. Hemoglobinuria
A. 18G, 1 ½” long B. Chest pain
B. 22G, 1” long C. Urticaria
C. 22G, 1 ½” long D. Distended neck veins
D. 25G, 5/8” long
Answer: A. Hemoglobinuria, the abnormal
Answer: D. A 25G, 5/8” needle is the presence of hemoglobin in the urine, indicates a
recommended size for insulin injection because hemolytic reaction (incompatibility of the donor’s
insulin is administered by the subcutaneous and recipient’s blood). In this reaction, antibodies
route. An 18G, 1 ½” needle is usually used for in the recipient’s plasma combine rapidly with
I.M. injections in children, typically in the donor RBC’s; the cells are hemolyzed in
vastus lateralis. A 22G, 1 ½” needle is usually either circulatory or reticuloendothelial system.
used for adult I.M. injections, which are typically Hemolysis occurs more rapidly in ABO
administered in the vastus lateralis or incompatibilities than in Rh incompatibilities.
ventrogluteal site. Chest pain and urticaria may be symptoms of
impending anaphylaxis. Distended neck veins are
25.The appropriate needle gauge for intradermal an indication of hypervolemia.
injection is:
30.Which of the following conditions may require
A. 20G fluid restriction?
B. 22G
C. 25G A. Fever
D. 26G B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
Answer: D. Because an intradermal injection does D. Dehydration
not penetrate deeply into the skin, a small-bore
25G needle is recommended. This type of Answer: C. In real failure, the kidney loses their
injection is used primarily to administer antigens ability to effectively eliminate wastes and fluids.
to evaluate reactions for allergy or sensitivity Because of this, limiting the patient’s intake of
studies. A 20G needle is usually used for I.M. oral and I.V. fluids may be necessary. Fever,
injections of oilbased medications; a 22G needle chronic obstructive pulmonary disease, and
for I.M. injections; and a 25G needle, for I.M. dehydration are conditions for which fluids should
injections; and a 25G needle, for subcutaneous be encouraged.
insulin injections.
31.All of the following are common signs and
26.Parenteral penicillin can be administered as symptoms of phlebitis except:
an:
A. Pain or discomfort at the IV insertion site
A. IM injection or an IV solution B. Edema and warmth at the IV insertion site
B. IV or an intradermal injection C. A red streak exiting the IV insertion site
C. Intradermal or subcutaneous injection D. Frank bleeding at the insertion site
D. IM or a subcutaneous injection
Answer: D. Phlebitis, the inflammation of a vein,
Answer: A. Parenteral penicillin can be can be caused by chemical irritants (I.V. solutions
administered I.M. or added to a solution and or medications), mechanical irritants (the needle
given I.V. It cannot be administered or catheter used during venipuncture or
subcutaneously or intradermally. cannulation), or a localized allergic reaction to the
needle or catheter. Signs and symptoms of
27.The physician orders gr 10 of aspirin for a phlebitis include pain or discomfort, edema and
patient. The equivalent dose in milligrams is: heat at the I.V. insertion site, and a red streak
going up the arm or leg from the I.V. insertion
A. 0.6 mg site.
B. 10 mg
C. 60 mg 32.The best way of determining whether a patient
D. 600 mg has learned to instill ear medication properly is
for the nurse to:
Answer: D. gr 10 x 60mg/gr 1 = 600 mg
A. Ask the patient if he/she has used ear
28.The physician orders an IV solution of dextrose drops before
5% in water at 100ml/hour. What would the flow B. Have the patient repeat the nurse’s
rate be if the drop factor is 15 gtt = 1 ml? instructions using her own words
C. Demonstrate the procedure to the patient
A. 5 gtt/minute and encourage to ask questions
B. 13 gtt/minute D. Ask the patient to demonstrate the
C. 25 gtt/minute procedure
D. 50 gtt/minute
