NP1
4.hWhichhofhthehfollowinghevaluationhdoeshthehnurse 7.hAhwomanhhashreturnedhfrom hsurgeryhafterhahrighth
makehwhenhthehvenipuncturehsitehhashanhobservab
h mastectomyhwithhanhIVhofh0.9%hNaClhinfusinghath10
FUNDAMENTALShOFhNURSING:
lehswellinghandhishtenderhandhcoolhtohtouch?h* 0hcc/hourhintohherhlefthforearm.hSeveralhhourshlater,h
1.hThehhomehhealthhcarehnursehishcaringhforhahclient
1hpoint thehIVhinfiltrates.hThehnursehishsupervisinghahstudent
h withhcancerhwhohishcomplaininghofhacutehpain.hTheh
nursehpreparinghtohinserthahnewhperipheralhintraven
mosthappropriatehdeterminationhofhthehclient’shpainh
h
a.hAnhinfectionhhashdeveloped
b.hBleedinghintohthehsurrounding htissuehhas hoccurr oushcatheter.hThehnursehwouldhintervenehinhwhichho
shouldhincludehwhichhassessment?h ed
c.hThehIVhsitehwas hinfiltrated fhthehfollowinghsituations?h*
a.hNonverbalhcueshfrom hthehclient
b.hThehnurse’shimpression hofhthehclient’s hpain d.hAhphlebitishishdeveloping 1hpoint
c.hThehclient’s hpainhrating
d.hPainhrelief hafter happropriatehnursinghintervention 5.hAhclienthwhohishreceiving hahcontinuous hintravenou A.hThehstudenthnursehselectshahsitehwherehthehvein
sharehsofthandhelastic.
shtherapyhishcomplaininghofhsuddenhdyspnea,hcough BhThehstudent hnursehselectshahsitehonhthehproximalh
2.hThehnursehreviewshthehbloodhgashresultshofhahclie
,handhtachycardia.hThehnursehauscultates hcracklesh portionhofhthehleftharm.
nthwithhatelectasis.hThehnursehanalyzeshthehresultsh C.hThehstudent hnursehselectshahsitehclosehtohthehjoi
bilaterally.hInhdetermininghwhathactionhtohtakehnext,h nthtohprovidehfor hstability.
andhdetermines hthaththehclienthishexperiencinghrespi
whichhofhthehfollowinghfactorshshouldhthehnursehcon DhThehstudenthnursehholds hthehskinhtauthtohstabilize
ratoryhacidosis.hWhichhresulthvalidateshthehnurse’shfi htheh vein.
sider?h*
ndings?h*
1hpoint 8.hAhclienthwhohishreceiving hahbloodhtransfusionhexp
a.hpHh7.25,hPCO2h50hmm hHg erienceshahhemolytichreaction.hThehnursehwouldhant
b.hpHh7.35,hPCO2h40hmm hHg a.hThehclienthis happrehensivehabouthreceivinghconti
c.hpHh7.50,hPCO2h52hmm hHg nuous hIVhfluids icipatehwhichhofhthehfollowinghassessmenthfindings?
d.hpHh7.52,hPCO2h28hmm hHg b.hThehclienthhashdevelopedhahrespiratoryhinfectionh
h *
orhpneumonia
3.hAhclienthwhohishfoundhunresponsivehhasharterialhb c.hThehclienthishexhibitinghsignshofhhypervolemia 1hpoint
d.hThehclienthis hexperiencinghinternalhbleeding
loodhgaseshdrawnhandhthehresultshindicatehthehfollo A.hHypotension, hbackache, hlowhback hpain,hfever.
wing:hpHhish7.15,hPCO2hish58hmmhHg,handhHCO3his 6.hThehnursehwouldhmonitorhahpatienthusinghsodium h B.hWethbreathhsounds,hseverehshortness hofhbreath.
C.hChillshandhfeverhoccurring habouthanhhour hafterhth
h 23hmEq/L.hThehnursehinterpretshthehresultshashindic bicarbonatehtohtreathgastrichhyperacidityhforhsignsha ehinfusion hstarted.
ndhsymptomshof:h* D.hUrticaria, hitching,hrespiratoryhdistress.
atinghwhichhcondition?h*
1hpoint 9.hThehnursehishsupervising hthehstaffhcaringhforhfourh
a.hMetabolic halkalosis
a.hRespiratoryhacidosis, huncompensated b.hHyperkalemia clientshreceivinghbloodhtransfusions.hWhichhofhthehf
b.hMetabolic hacidosis, hcompensated c.hHypercalcemia
ourhclientshshouldhthehnursehseehFIRST?h*
c.hMetabolichacidosis,huncompensated d.hMetabolic hacidosis
d.hRespiratoryhacidosis, hcompensated
A.hAhclienthcomplaininghofhahheadache.
B.hAhclienthvomiting.
,C.hAhclienthcomplaining hofhitching. C.hExplainhthehprocedure htohthehpatient. hInserththeh A.hTachycardia
D.hAhclienthwithhneck hveinhdistention catheter hwhilehgentlyhapplyinghsuction,handhwithdra B.hDryhmucoushmembranes
whusinghahtwistinghmotion. C.hProlonged hcapillaryhrefill
10.hThehLPNhishassistinghthehRNhwithhpreparationhfo D.hInserththehsuctionhcatheterhuntilhresistance his hme D.hSunkenhfontanelles
t,hthenhwithdrawhithslightly. hApplyhsuctionhintermitte
rhadministeringhahtransfusionhofhwholehblood.hWhich ntlyhashthehcatheter his hwithdrawn. 16.hNursehMariehinsertedhanhIVhaccesshaththehlefthce
h actionhbyhthehnursehpredisposes hthehclienthtohthehd phalichveinhofhthehclient.hTohsecurehthehIVhaccesshsit
13.hOnhnursinghrounds,hahpatienthishfoundhlyinghonht
evelopmenthofhhyperkalemia?h* e,hshehshould:h*
hehfloor.hWhichhstatementhwouldhbehmosthappropria
tehforhthehnursehtohdocumenthinhthehpatient’shmedica 1hpoint
A.hAllowinghthehbloodhtohwarm htohroom htemperature
lhrecord?h* A.hUsehahpaddedhboardhtohsecurehthehextremity
B.hAdministeringhbloodhthathish24hhours hold
B.hRestrainhallhfourhextremities
C.hAdministering hbloodhwithh18-gaugehneedle 1hpoint C.hRestrainhthehextremityhtohthehbed’shsidehrail
D.hFillinghthehdriphchamber hbelowhthehlevelhofhthehfil
D.hAllowhthehextremityhtohbehloose
ter a.h“Ithis hmosthlikelyhthaththehpatient hattemptedhtohcli
mbhoverhthehsidehrailshandhfell”.
b.h“Uponhentering hthehroom,hthehpatient hwashfoundh 17.hAhnursehishinsertinghahnasogastric htubehinhanhad
11.hWhichhofhthehfollowinghishmosthimportanthtohhav
lyinghonhthehfloor.” ulthclient.hDuringhthehprocedure,hthehclienthbeginshto
ehonhhandhduringhahbloodhtransfusion?h* c.h“Thehpatient hhadhbeenhrestless hallheveninghandh
washtryinghtohgethouthofhbed”. h coughhandhhashdifficultyhbreathing.hWhichhofhthehfol
1hpoint d.h“Thehpresencehofhahbedhalarm hcouldhhavehpreve
lowinghishthehappropriatehnursinghaction?h*
ntedhthehfall.”
A.hAnhalternativehIVhline
B.hDiphenhydramine 1hpoint
C.hAcetaminophen 14.hInhassessinghthehclient’shcondition,hNursehMarie
A.hQuicklyhinserththehtube.
D.hAhtourniquet ishawarehthaththehmosthimportanthdeterminanthofhth
h B.hNotifyhthehphysician himmediately.
ehpercenthofhfluidhlosshinhinfantshandhyoungerhchildr C.hRemove hthehtubehandhreinserthwhenhthehrespirat
12.hAh48-year- oryhdistresshsubsides.
oldhmanhwithhanhendotrachealhtubehneedshsuctionin enhish* D.hPullhback honhthehtubehandhwaithuntilhthehrespirat
oryhdistresshsubsides.
g.hWhichhofhthehfollowinghstatementshishanhaccurate 1hpoint
h descriptionhofhhowhthehnursehshouldhperform hthehpr A.hCapillaryhrefillh>2hsecs 18.hAhnursehishcaringhforhahclienthimmediatelyhafterhr
B.hDecreasedhlevelhofhconsciousness emovalhofhthehendotrachealhtube.hThehnursehreports
ocedure?h*
C.hWeight
D.hDecreasedhskinhturgor h whichhofhthehfollowinghsignshimmediatelyhifhexperie
ncedhbyhthehclient?h*
A.hInserththehsuctionhcatheterhfourhincheshintohtheht
ube.hApplyhsuctionhforh30hseconds,husinghahtwirling h 1hpoint
motionhashthehcatheter his hwithdrawn. 15.hNursehMariehshouldhassesshforhwhichhearlyhsig
B.hHyperoxygenatehthehclienthandhthenhinserththehs A.hStridor
nhofhdehydrationhinhthishclient?h*
uctionhcatheter hintohthehtube.hSuctionhwhileh youhre B.hOccasional hpink-tingedhsputum
movehthehcatheter husinghahback handhforthhmotion. 1hpoint C.hRespiratoryhratehofh24hbreaths/min
D.hAhfewhbasilarhlunghcrackles honhthehright
, A.htinnitus, hvertigo,hblurredhvision.
19.hThehnursehcheckshforhresidualhbeforehadministe
B.hfever,hmalaise, hanorexia.
ringhahbolushtubehfeedinghtohahclienthwithhahnasogas C.hdiaphoresis,hconfusion, htachycardia.
A.h59hmg/dL. D.hhyperpnea,hflushedhface,hdiarrhea.
trichtubehandhobtainshahresidualhamounthofh150hmL.h B.h75hmg/dL.
C.h108hmg/dL.
Whathishthehappropriatehactionhforhthehnursehtohtake D.h119hmg/dL. 25.hAhnursehishcaringhforhahclienthreceivinghtotalhpar
? h* enteralhnutritionh(TPN).hThehnursehimplementshwhic
22.hThehnursehassesseshahclienthwithhanhileostomyhf
1hpoint hhactionhtohdecreasehthehrisk hofhinfection?h*
orhpossiblehdevelopmenthofhwhichhofhthehfollowingha
A.hHoldhthehfeeding.
B.hReinstillhthehamounthandhcontinue hwithhadminist cid-basehimbalances?h*
eringhthehfeeding. A.hAssessinghvitalhsigs hath4-hourhintervals
1hpoint B.hInstructinghthehclienthtohperform hahValsalvahman
C.hElevatehthehclient’s hheadhathleasth45hdegreeshan
dhadministerhthehfeeding. euverhduring hintravenous htubinghchanges
A.hRespiratoryhacidosis C.hAdminister hacetaminophenhbeforehchanginghtheh
D.hDiscardhthehresidualhamounthandhproceedhwithha B.hMetabolichacidosis
dministering hthehfeeding centralhlinehdressing
C.hMetabolic halkalosis
D.hUsinghaseptichtechniquehinhhandlinghthehTPNhso
D.hRespiratoryhalkalosis
lutionhandhtubing
20.hThehnursehishplanninghtohobtainhanharterialhbloo
dhgash(ABG)hfrom hthehradialharteryhofhahclienthwithhc 23.hAhclienthwithhCOPDhhashahknowledgehdeficithrel
26.hThehnursehishcaringhforhahhomeboundhclienthwith
atedhtohpositionshusedhtohbreathehmoreheasily.hTheh
hronichobstructivehpulmonaryhdisease(COPD).hTohp h ahurinaryhcatheter.hThehclient’shhusbandhstateshthat
reventhbleedinghafterhthehprocedure,hthehnursehshou nursehplanshtohteachhthehclienthto:h*
h hehthinkshthehcatheterhishobstructed.hWhichhofhthehf
ldhplanhtimehforhwhichhactivityhafterhtheharterialhbloo 1hpoint ollowinghobservations hwouldhconfirmhthishsuspicion
dhishdrawn?h* A.hLiehonhthehsidehwithhthehheadhofhthehbedhathah45h ? h*
degreehangle
1hpoint B.hSithbolthupright hinhbedhwithhtheharmshcrossedhov 1hpoint
erhthehchest
A.hHoldinghahwarm hcompresshoverhthehpuncture hsit A.hThehnurse hnoteshthaththehbladderhishdistended.
C.hSithonhthehedgehofhthehbedhwithhtheharmshleaning
ehforh5hminutes B.hThehclient hcomplains hofhahconstanthurgehtohvoid.
honh an hover h bedh table
B.hEncouraging hthehclienthtohopenhandhclosehthehha C.hThehnursehnotes hthaththehurinehishconcentrated.
D.hSithinhahreclining hchair htiltedhslightlyhback hwithhth
ndhrapidlyhfor h2hminutes D.hThehclient hcomplainshofhahburninghsensation
ehfeethelevated
C.hApplyinghpressurehtohthehpuncture hsitehbyhapplyi
nghah2hXh2hgauzehforh5hminutes
27.hAh30-year-
D.hHavinghthehclienthkeephthehradialhpulsehpuncture 24.hAh69-year-
hsite hinh ah dependent h position hfor h 5hminutes oldhclienthishadmittedhtohthehprogressivehcarehunithwi
oldhwomanhhashbeenhreceivinghtotalhparenteralhnutri
thhahC5hfracturehfrom hahmotorcyclehcollision.hWhichh
21.hThehnursehishteachinghthehclienthabouthhomehblo tionh(TPN)hforhseveralhweeks.hIfhthehTPNhwerehabru
assessmenthwouldhtakehPRIORITY?h*
odhglucosehmonitoring.hWhichhofhthehfollowinghbloo ptlyhdiscontinued,hthehnursehwouldhexpecththehpatie
nthtohexhibith* 1hpoint
dhglucosehmeasurementshindicateshhypoglycemia
? h* 1hpoint a.hBladder hdistention
, b.hNeurologicalhdeficit d.hpHh7.31,hCO2h31hmmHg,hHCO3h20hmEq/L b.hHandshdown
c.hPulsehoximetryhreadings c.hHandshonhthehside
d.hThehclient’shfeelingshabouththehinjury 31.hWhichhofhthesehtaskshmayhNursehPalomahdeleg d.hHandshonhthehchest
28.hAhclienthscheduledhforhanharteriogram htellshthehn atehtohahnursinghassistanthinhcaringhforhPatienthRichi 35.hThehpatienthwithhCOPDhhashahpulsehoximetryhre
urse.h“I’mhafraidhtohhavehthathtesthdone.”hThehnurse’ e?h* adinghofh90%.hWhathishthehpriorityhnursinghactionhfor
shbesthresponsehwouldhbe:h* 1hpoint h thishpatient?h*
1hpoint A.hPerforminghbasichlifehsupport 1hpoint
B.hClienthambulation
A.hRemainhsilenthbecausehthishishahcommonhfear hof C.hDatahandhlaboratoryhinterpretation a.hGivehlowhflowho2
hsurgical hclients. D.hClientheducation b.hReporthtohdoctor
B.hSay,h”Whathabouththehtesthcauses h youhfear?” c.hDocumenthfindings
C.hSay,h“Areh youhafraidhthath youhwon’thwakeup?” 32.hThehpatienthrefusedhthehmedicationhthathishorder d.hSuctionhclient
D.hSay,h“Youhhavehnothinghtohbehafraidhof.hYouhdoc
torhdoes hthis hsamehsurgeryhtwohorhthreehtimeshahwe edhforhhim.hWhathishthehpriorityhnursinghintervention
36.hWhathishthehlocationhofhpulsehoximeterhifhthehpati
ek.”
? h*
enthhashhemorrhagic hshock?h*
29.hWhichhofhthehfollowinghteachingshbyhahstudenthn 1hpoint
1hpoint
ursehtohanhelderlyhclienthmusthbehcorrectedhbyhahPH a.hAccepthrefusalhandhdocument a.hFinger
b.hReporthtohthehdoctor
N?h* b.hEarlobe
c.hExplainhimportancehofhthehdrug
c.hForehead
1hpoint d.hDirecthhim htohthehheadhnurse
d.hToes
a.h“Consulth your hdoctorhwithh your hlisthofhdrugshtohse 33.hWhichharehtruehregardinghproperhhandlinghtechn
ehifh yourhkidneys hcanhaccommodate hthem” 37.hWhathshouldhbehdonehifhtherehishsunlighthonhtheh
b.h“Usehthirsthashahreliablehindicator hforhthehneedhtoh ique?h*
pulsehoximeter?h
drink handhrehydrate”
c.h“Avoidhdrinkinghathnighthsoh youhwillhnothneedhtohg
a.hAllhinvasivehprocedures harehperformedhviahsterile
ethuphfrom hbedhtohurinate” a.hCoverhsensor
htechnique
d.h“Dohnothoveruse hlaxativeshtohmanageh yourhfrequ b.hRepositionhsensorhonhopposite harm
b.hOralhcarehishsterilehtechnique c.hDohnothing hithdoesn’thaffecthsensor
enthconstipation”
c.hNasopharyngealhSuctioninghshouldhbehperforme
d.hRemovehsensor handhputhinhthehtoes
dhviahsterilehtechnique
30.Thehpatient’shABGhresulthrevealshpresencehofhre d.hLumbarhpuncture his hperformedhviahstandardhprec
autions 38.hWhathishthehexpectedhABGhvalueshforhpatienthwi
spiratoryhacidosis.hWhichhamonghthesehvalueshwoul
thhhyperventilation?h*
dhyouhexpecthtohsee?h* 34.hWhathshouldhbehdonehafterhwashinghyourhhands
1hpoint
1hpoint h withhsoaphandhwater?h*
a.hRespiratoryhalkalosis
a.hpHh7.35,hCO2h39hmmHg,hHCO3h24hmEq/L 1hpoint b.hRespiratoryhacidosis
b.hpHh7.47,hCO2h30hmmHg,hHCO3h22hmEq/L c.hMetabolic halkalosis
c.hpHh7.32,hCO2h49hmmHg,hHCO3h29hmEq/L a.hHandshup d.hMetabolic hacidosis
4.hWhichhofhthehfollowinghevaluationhdoeshthehnurse 7.hAhwomanhhashreturnedhfrom hsurgeryhafterhahrighth
makehwhenhthehvenipuncturehsitehhashanhobservab
h mastectomyhwithhanhIVhofh0.9%hNaClhinfusinghath10
FUNDAMENTALShOFhNURSING:
lehswellinghandhishtenderhandhcoolhtohtouch?h* 0hcc/hourhintohherhlefthforearm.hSeveralhhourshlater,h
1.hThehhomehhealthhcarehnursehishcaringhforhahclient
1hpoint thehIVhinfiltrates.hThehnursehishsupervisinghahstudent
h withhcancerhwhohishcomplaininghofhacutehpain.hTheh
nursehpreparinghtohinserthahnewhperipheralhintraven
mosthappropriatehdeterminationhofhthehclient’shpainh
h
a.hAnhinfectionhhashdeveloped
b.hBleedinghintohthehsurrounding htissuehhas hoccurr oushcatheter.hThehnursehwouldhintervenehinhwhichho
shouldhincludehwhichhassessment?h ed
c.hThehIVhsitehwas hinfiltrated fhthehfollowinghsituations?h*
a.hNonverbalhcueshfrom hthehclient
b.hThehnurse’shimpression hofhthehclient’s hpain d.hAhphlebitishishdeveloping 1hpoint
c.hThehclient’s hpainhrating
d.hPainhrelief hafter happropriatehnursinghintervention 5.hAhclienthwhohishreceiving hahcontinuous hintravenou A.hThehstudenthnursehselectshahsitehwherehthehvein
sharehsofthandhelastic.
shtherapyhishcomplaininghofhsuddenhdyspnea,hcough BhThehstudent hnursehselectshahsitehonhthehproximalh
2.hThehnursehreviewshthehbloodhgashresultshofhahclie
,handhtachycardia.hThehnursehauscultates hcracklesh portionhofhthehleftharm.
nthwithhatelectasis.hThehnursehanalyzeshthehresultsh C.hThehstudent hnursehselectshahsitehclosehtohthehjoi
bilaterally.hInhdetermininghwhathactionhtohtakehnext,h nthtohprovidehfor hstability.
andhdetermines hthaththehclienthishexperiencinghrespi
whichhofhthehfollowinghfactorshshouldhthehnursehcon DhThehstudenthnursehholds hthehskinhtauthtohstabilize
ratoryhacidosis.hWhichhresulthvalidateshthehnurse’shfi htheh vein.
sider?h*
ndings?h*
1hpoint 8.hAhclienthwhohishreceiving hahbloodhtransfusionhexp
a.hpHh7.25,hPCO2h50hmm hHg erienceshahhemolytichreaction.hThehnursehwouldhant
b.hpHh7.35,hPCO2h40hmm hHg a.hThehclienthis happrehensivehabouthreceivinghconti
c.hpHh7.50,hPCO2h52hmm hHg nuous hIVhfluids icipatehwhichhofhthehfollowinghassessmenthfindings?
d.hpHh7.52,hPCO2h28hmm hHg b.hThehclienthhashdevelopedhahrespiratoryhinfectionh
h *
orhpneumonia
3.hAhclienthwhohishfoundhunresponsivehhasharterialhb c.hThehclienthishexhibitinghsignshofhhypervolemia 1hpoint
d.hThehclienthis hexperiencinghinternalhbleeding
loodhgaseshdrawnhandhthehresultshindicatehthehfollo A.hHypotension, hbackache, hlowhback hpain,hfever.
wing:hpHhish7.15,hPCO2hish58hmmhHg,handhHCO3his 6.hThehnursehwouldhmonitorhahpatienthusinghsodium h B.hWethbreathhsounds,hseverehshortness hofhbreath.
C.hChillshandhfeverhoccurring habouthanhhour hafterhth
h 23hmEq/L.hThehnursehinterpretshthehresultshashindic bicarbonatehtohtreathgastrichhyperacidityhforhsignsha ehinfusion hstarted.
ndhsymptomshof:h* D.hUrticaria, hitching,hrespiratoryhdistress.
atinghwhichhcondition?h*
1hpoint 9.hThehnursehishsupervising hthehstaffhcaringhforhfourh
a.hMetabolic halkalosis
a.hRespiratoryhacidosis, huncompensated b.hHyperkalemia clientshreceivinghbloodhtransfusions.hWhichhofhthehf
b.hMetabolic hacidosis, hcompensated c.hHypercalcemia
ourhclientshshouldhthehnursehseehFIRST?h*
c.hMetabolichacidosis,huncompensated d.hMetabolic hacidosis
d.hRespiratoryhacidosis, hcompensated
A.hAhclienthcomplaininghofhahheadache.
B.hAhclienthvomiting.
,C.hAhclienthcomplaining hofhitching. C.hExplainhthehprocedure htohthehpatient. hInserththeh A.hTachycardia
D.hAhclienthwithhneck hveinhdistention catheter hwhilehgentlyhapplyinghsuction,handhwithdra B.hDryhmucoushmembranes
whusinghahtwistinghmotion. C.hProlonged hcapillaryhrefill
10.hThehLPNhishassistinghthehRNhwithhpreparationhfo D.hInserththehsuctionhcatheterhuntilhresistance his hme D.hSunkenhfontanelles
t,hthenhwithdrawhithslightly. hApplyhsuctionhintermitte
rhadministeringhahtransfusionhofhwholehblood.hWhich ntlyhashthehcatheter his hwithdrawn. 16.hNursehMariehinsertedhanhIVhaccesshaththehlefthce
h actionhbyhthehnursehpredisposes hthehclienthtohthehd phalichveinhofhthehclient.hTohsecurehthehIVhaccesshsit
13.hOnhnursinghrounds,hahpatienthishfoundhlyinghonht
evelopmenthofhhyperkalemia?h* e,hshehshould:h*
hehfloor.hWhichhstatementhwouldhbehmosthappropria
tehforhthehnursehtohdocumenthinhthehpatient’shmedica 1hpoint
A.hAllowinghthehbloodhtohwarm htohroom htemperature
lhrecord?h* A.hUsehahpaddedhboardhtohsecurehthehextremity
B.hAdministeringhbloodhthathish24hhours hold
B.hRestrainhallhfourhextremities
C.hAdministering hbloodhwithh18-gaugehneedle 1hpoint C.hRestrainhthehextremityhtohthehbed’shsidehrail
D.hFillinghthehdriphchamber hbelowhthehlevelhofhthehfil
D.hAllowhthehextremityhtohbehloose
ter a.h“Ithis hmosthlikelyhthaththehpatient hattemptedhtohcli
mbhoverhthehsidehrailshandhfell”.
b.h“Uponhentering hthehroom,hthehpatient hwashfoundh 17.hAhnursehishinsertinghahnasogastric htubehinhanhad
11.hWhichhofhthehfollowinghishmosthimportanthtohhav
lyinghonhthehfloor.” ulthclient.hDuringhthehprocedure,hthehclienthbeginshto
ehonhhandhduringhahbloodhtransfusion?h* c.h“Thehpatient hhadhbeenhrestless hallheveninghandh
washtryinghtohgethouthofhbed”. h coughhandhhashdifficultyhbreathing.hWhichhofhthehfol
1hpoint d.h“Thehpresencehofhahbedhalarm hcouldhhavehpreve
lowinghishthehappropriatehnursinghaction?h*
ntedhthehfall.”
A.hAnhalternativehIVhline
B.hDiphenhydramine 1hpoint
C.hAcetaminophen 14.hInhassessinghthehclient’shcondition,hNursehMarie
A.hQuicklyhinserththehtube.
D.hAhtourniquet ishawarehthaththehmosthimportanthdeterminanthofhth
h B.hNotifyhthehphysician himmediately.
ehpercenthofhfluidhlosshinhinfantshandhyoungerhchildr C.hRemove hthehtubehandhreinserthwhenhthehrespirat
12.hAh48-year- oryhdistresshsubsides.
oldhmanhwithhanhendotrachealhtubehneedshsuctionin enhish* D.hPullhback honhthehtubehandhwaithuntilhthehrespirat
oryhdistresshsubsides.
g.hWhichhofhthehfollowinghstatementshishanhaccurate 1hpoint
h descriptionhofhhowhthehnursehshouldhperform hthehpr A.hCapillaryhrefillh>2hsecs 18.hAhnursehishcaringhforhahclienthimmediatelyhafterhr
B.hDecreasedhlevelhofhconsciousness emovalhofhthehendotrachealhtube.hThehnursehreports
ocedure?h*
C.hWeight
D.hDecreasedhskinhturgor h whichhofhthehfollowinghsignshimmediatelyhifhexperie
ncedhbyhthehclient?h*
A.hInserththehsuctionhcatheterhfourhincheshintohtheht
ube.hApplyhsuctionhforh30hseconds,husinghahtwirling h 1hpoint
motionhashthehcatheter his hwithdrawn. 15.hNursehMariehshouldhassesshforhwhichhearlyhsig
B.hHyperoxygenatehthehclienthandhthenhinserththehs A.hStridor
nhofhdehydrationhinhthishclient?h*
uctionhcatheter hintohthehtube.hSuctionhwhileh youhre B.hOccasional hpink-tingedhsputum
movehthehcatheter husinghahback handhforthhmotion. 1hpoint C.hRespiratoryhratehofh24hbreaths/min
D.hAhfewhbasilarhlunghcrackles honhthehright
, A.htinnitus, hvertigo,hblurredhvision.
19.hThehnursehcheckshforhresidualhbeforehadministe
B.hfever,hmalaise, hanorexia.
ringhahbolushtubehfeedinghtohahclienthwithhahnasogas C.hdiaphoresis,hconfusion, htachycardia.
A.h59hmg/dL. D.hhyperpnea,hflushedhface,hdiarrhea.
trichtubehandhobtainshahresidualhamounthofh150hmL.h B.h75hmg/dL.
C.h108hmg/dL.
Whathishthehappropriatehactionhforhthehnursehtohtake D.h119hmg/dL. 25.hAhnursehishcaringhforhahclienthreceivinghtotalhpar
? h* enteralhnutritionh(TPN).hThehnursehimplementshwhic
22.hThehnursehassesseshahclienthwithhanhileostomyhf
1hpoint hhactionhtohdecreasehthehrisk hofhinfection?h*
orhpossiblehdevelopmenthofhwhichhofhthehfollowingha
A.hHoldhthehfeeding.
B.hReinstillhthehamounthandhcontinue hwithhadminist cid-basehimbalances?h*
eringhthehfeeding. A.hAssessinghvitalhsigs hath4-hourhintervals
1hpoint B.hInstructinghthehclienthtohperform hahValsalvahman
C.hElevatehthehclient’s hheadhathleasth45hdegreeshan
dhadministerhthehfeeding. euverhduring hintravenous htubinghchanges
A.hRespiratoryhacidosis C.hAdminister hacetaminophenhbeforehchanginghtheh
D.hDiscardhthehresidualhamounthandhproceedhwithha B.hMetabolichacidosis
dministering hthehfeeding centralhlinehdressing
C.hMetabolic halkalosis
D.hUsinghaseptichtechniquehinhhandlinghthehTPNhso
D.hRespiratoryhalkalosis
lutionhandhtubing
20.hThehnursehishplanninghtohobtainhanharterialhbloo
dhgash(ABG)hfrom hthehradialharteryhofhahclienthwithhc 23.hAhclienthwithhCOPDhhashahknowledgehdeficithrel
26.hThehnursehishcaringhforhahhomeboundhclienthwith
atedhtohpositionshusedhtohbreathehmoreheasily.hTheh
hronichobstructivehpulmonaryhdisease(COPD).hTohp h ahurinaryhcatheter.hThehclient’shhusbandhstateshthat
reventhbleedinghafterhthehprocedure,hthehnursehshou nursehplanshtohteachhthehclienthto:h*
h hehthinkshthehcatheterhishobstructed.hWhichhofhthehf
ldhplanhtimehforhwhichhactivityhafterhtheharterialhbloo 1hpoint ollowinghobservations hwouldhconfirmhthishsuspicion
dhishdrawn?h* A.hLiehonhthehsidehwithhthehheadhofhthehbedhathah45h ? h*
degreehangle
1hpoint B.hSithbolthupright hinhbedhwithhtheharmshcrossedhov 1hpoint
erhthehchest
A.hHoldinghahwarm hcompresshoverhthehpuncture hsit A.hThehnurse hnoteshthaththehbladderhishdistended.
C.hSithonhthehedgehofhthehbedhwithhtheharmshleaning
ehforh5hminutes B.hThehclient hcomplains hofhahconstanthurgehtohvoid.
honh an hover h bedh table
B.hEncouraging hthehclienthtohopenhandhclosehthehha C.hThehnursehnotes hthaththehurinehishconcentrated.
D.hSithinhahreclining hchair htiltedhslightlyhback hwithhth
ndhrapidlyhfor h2hminutes D.hThehclient hcomplainshofhahburninghsensation
ehfeethelevated
C.hApplyinghpressurehtohthehpuncture hsitehbyhapplyi
nghah2hXh2hgauzehforh5hminutes
27.hAh30-year-
D.hHavinghthehclienthkeephthehradialhpulsehpuncture 24.hAh69-year-
hsite hinh ah dependent h position hfor h 5hminutes oldhclienthishadmittedhtohthehprogressivehcarehunithwi
oldhwomanhhashbeenhreceivinghtotalhparenteralhnutri
thhahC5hfracturehfrom hahmotorcyclehcollision.hWhichh
21.hThehnursehishteachinghthehclienthabouthhomehblo tionh(TPN)hforhseveralhweeks.hIfhthehTPNhwerehabru
assessmenthwouldhtakehPRIORITY?h*
odhglucosehmonitoring.hWhichhofhthehfollowinghbloo ptlyhdiscontinued,hthehnursehwouldhexpecththehpatie
nthtohexhibith* 1hpoint
dhglucosehmeasurementshindicateshhypoglycemia
? h* 1hpoint a.hBladder hdistention
, b.hNeurologicalhdeficit d.hpHh7.31,hCO2h31hmmHg,hHCO3h20hmEq/L b.hHandshdown
c.hPulsehoximetryhreadings c.hHandshonhthehside
d.hThehclient’shfeelingshabouththehinjury 31.hWhichhofhthesehtaskshmayhNursehPalomahdeleg d.hHandshonhthehchest
28.hAhclienthscheduledhforhanharteriogram htellshthehn atehtohahnursinghassistanthinhcaringhforhPatienthRichi 35.hThehpatienthwithhCOPDhhashahpulsehoximetryhre
urse.h“I’mhafraidhtohhavehthathtesthdone.”hThehnurse’ e?h* adinghofh90%.hWhathishthehpriorityhnursinghactionhfor
shbesthresponsehwouldhbe:h* 1hpoint h thishpatient?h*
1hpoint A.hPerforminghbasichlifehsupport 1hpoint
B.hClienthambulation
A.hRemainhsilenthbecausehthishishahcommonhfear hof C.hDatahandhlaboratoryhinterpretation a.hGivehlowhflowho2
hsurgical hclients. D.hClientheducation b.hReporthtohdoctor
B.hSay,h”Whathabouththehtesthcauses h youhfear?” c.hDocumenthfindings
C.hSay,h“Areh youhafraidhthath youhwon’thwakeup?” 32.hThehpatienthrefusedhthehmedicationhthathishorder d.hSuctionhclient
D.hSay,h“Youhhavehnothinghtohbehafraidhof.hYouhdoc
torhdoes hthis hsamehsurgeryhtwohorhthreehtimeshahwe edhforhhim.hWhathishthehpriorityhnursinghintervention
36.hWhathishthehlocationhofhpulsehoximeterhifhthehpati
ek.”
? h*
enthhashhemorrhagic hshock?h*
29.hWhichhofhthehfollowinghteachingshbyhahstudenthn 1hpoint
1hpoint
ursehtohanhelderlyhclienthmusthbehcorrectedhbyhahPH a.hAccepthrefusalhandhdocument a.hFinger
b.hReporthtohthehdoctor
N?h* b.hEarlobe
c.hExplainhimportancehofhthehdrug
c.hForehead
1hpoint d.hDirecthhim htohthehheadhnurse
d.hToes
a.h“Consulth your hdoctorhwithh your hlisthofhdrugshtohse 33.hWhichharehtruehregardinghproperhhandlinghtechn
ehifh yourhkidneys hcanhaccommodate hthem” 37.hWhathshouldhbehdonehifhtherehishsunlighthonhtheh
b.h“Usehthirsthashahreliablehindicator hforhthehneedhtoh ique?h*
pulsehoximeter?h
drink handhrehydrate”
c.h“Avoidhdrinkinghathnighthsoh youhwillhnothneedhtohg
a.hAllhinvasivehprocedures harehperformedhviahsterile
ethuphfrom hbedhtohurinate” a.hCoverhsensor
htechnique
d.h“Dohnothoveruse hlaxativeshtohmanageh yourhfrequ b.hRepositionhsensorhonhopposite harm
b.hOralhcarehishsterilehtechnique c.hDohnothing hithdoesn’thaffecthsensor
enthconstipation”
c.hNasopharyngealhSuctioninghshouldhbehperforme
d.hRemovehsensor handhputhinhthehtoes
dhviahsterilehtechnique
30.Thehpatient’shABGhresulthrevealshpresencehofhre d.hLumbarhpuncture his hperformedhviahstandardhprec
autions 38.hWhathishthehexpectedhABGhvalueshforhpatienthwi
spiratoryhacidosis.hWhichhamonghthesehvalueshwoul
thhhyperventilation?h*
dhyouhexpecthtohsee?h* 34.hWhathshouldhbehdonehafterhwashinghyourhhands
1hpoint
1hpoint h withhsoaphandhwater?h*
a.hRespiratoryhalkalosis
a.hpHh7.35,hCO2h39hmmHg,hHCO3h24hmEq/L 1hpoint b.hRespiratoryhacidosis
b.hpHh7.47,hCO2h30hmmHg,hHCO3h22hmEq/L c.hMetabolic halkalosis
c.hpHh7.32,hCO2h49hmmHg,hHCO3h29hmEq/L a.hHandshup d.hMetabolic hacidosis
