NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE1. This evaluation may be limited to the performance of one nurse or by the whole agency. This is done by

looking into the structure, process and outcome of care provided. This process of evaluation is called:a. process evaluationb. quality insurancec. nursing auditd. quality assurance

2. A client is confined in your unit. He says that he has difficulty sleeping because of the “ambience” in the unit. When evaluating the effect the setting has on the quality of care provided to the client the evaluation being done is called:

a. quality assuranceb. structure evaluationc. nursing auditd. quality assurance

3. The client is given a sponge bath, vital signs are checked, and medications are given on time. The evaluation of the care provided to him by the nurse is referred to as:

a. nursing auditb. outcome evaluationc. process evaluationd. quality improvement

4. As a result of the comfort measure done and medications administered to the client, some demonstrable changes are observed. These changes in the client’s condition when evaluated is referred to as:

a. outcome identificationb. quality improvementc. nursing evaluationd. outcome evaluation

5. The head nurse wants to evaluate the time it takes for the nurse to respond to client’s call. This type of quality evaluation is called:

a. quality improvementb. structure evaluationc. nursing auditd. process evaluation

6. Accuracy in recording of the vital signs is of utmost importance in the management of patient care. Special considerations to be observed when taking vital signs include the following EXCEPT:

a. frequent measurement done n the ICUexpose clients to more pathogensb. wait at least 30 minutes after excercising, eating or smoking before taking vital signsc. clients with acute neurologic deficits must be checked frequentlyd. use of games and stories to decrease anxiety in infants to assess vital signs

7. The nurse considers which of these to be CORRECT as when taking vital signs?a. Standard and uniform equipment are used to measure vital signs for all clients in the ward.b. Measurement and interpretation of vital signs can be delegated to nursing aides who have been well

trainedc. BP reading is routinely assessed in young infants and children to assess cardiac functioning.d. Baseline data of the client’s physiologic functioning are established through accurate measurement

of vital signs.8. The nurse obtained a BP reading of 120/ 80 when the client was in supine position. After an hour, the nurse

rechecked it and obtained a reading of 132/ 78 in supine position and 110/ 60 in a sitting position. The most appropriate action by the nurse is to:

a. get the client’s BP reading in the other armb. report the readings to the supervisor for appropriate nursing actionsc. assist the client to return to a supine positiond. conduct a physical assessment of the client

9. The nurse has to take the client’s thigh blood pressure. You will assist the client assume which correct position

a. side- lyingb. fowler’sc. slim’sd. supine, knees flexed

10. The nurse obtained a prior blood pressure reading of 70/ 40 mmHg from a male client. This time she could not obtain a reading by auscultation. The most appropriate nursing action would be to:

a. leave the BP cuff on the client so as not to disturb when checking the BP againb. take the client’s BP by palpation reporting to the physician any 20 mm Hg change in readingc. report to the physician immediately for proper interventiond. ask a nursing assistant to take blood pressure by auscultation.

11. While the nurse changes the patient’s gown, the infusion pump alarm turned on. The nurse’s priority should be to check first the:

a. intravenous site for occlusionb. presence of air in the tubingc. container if emptyd. tubing for kinks

12. The nurse discusses with the client’s wife health promoting activities that can help the client with cirrhosis of the liver in his ADL at home. Which among the following is the most appropriate measure the nurse can suggest?

a. good nutrition, avoid infection and abstain from alcoholb. take a glass of milk at bedtimec. avoid crowded areasd. ensure adequate rest, sleep and exercise

13. The staff nurses in the medical unit are planning total parenteral nutrition to prevent complication when administered through a central line. Which of the following interventions are most appropriate?

i. follow strict clean technique for all dressing changeii. promote adequate rest and limited activitiesiii. observe strict aseptic techniqueiv. cover insertion site with air occlusive dressingv. cover the insertion site with moisture- proof dressing

a. 2 & 3b. 3& 4c. 2, 4, 5d. 1, 3, 5

14. The nurse is assigned to a client with a diagnosis of cancer of the bladder, with attachment to an appliance for a standard urine collection at night. The nurse discusses with the wife the reason for the attachment. The best explanation should be to:

a. prevent urine leakageb. prevent urine drainagec. restrict fluid intaked. prevent urine reflux into the stoma and ureters

15. The nurses in the renal unit are reviewing the laboratory result of the clients. Which of the following laboratory results will NOT improve by dialysis treatment?

a. low hemoglobinb. elevated serum potassium levelc. elevated sodium leveld. elevated BUN and Creatinine

16. The incoming nurses in the renal unit are discussing the assessment findings of a 66 y/o client, male with chronic renal failure and hypertension. He has crackles in the lungs and weight gain from 145 lbs to 160 lbs. The nursing diagnosis that is appropriate for the above findings is:

a. fluid volume excess related to malfunctioning kidneysb. increase fluid intake related to chronic renal failurec. fluid volume deficit related to renal failure’d. fluid volume excess related to inability of the kidney to maintain fluid balance

17. A 16 year old female client got pregnant and was abandoned by her boyfriend. She visited a doctor’s clinic and asked the nurse if she could have an abortion. What should be the initial response of the nurse?

a. “Why not think it over then decide after careful assessment of the situation.”b. “You should not feel that way.”c. “What are your feelings about abortion?”d. “You seek advise from your parents.”

18. A 45 year old female client is admitted to a semi- private room for elective surgery. She tells the nurse that her prayer group will be coming to pray for her. The group arrived, starting chanting inside the room. What should be the appropriate action of the nurse?

a. Arrange for the group to go to the prayer room or chapel if availableb. Ask the client’s roommate for their understanding and respect the other clients wishc. Ignore the prayer group and allow their chantingd. Call the attention of the group and pray quietly

19. A 40 year old male client has been confined in a semi- private room for 2 days until another client came. He asks the nurse what the condition of the client is. Which of the following should be the nurse’s response?

a. advise him that all client’s condition are held in confidenceb. tell him to ask the new client himselfc. explain in layman’s term the condition of the new clientd. ask the client what he wants to know

20. A nurse who functions from an ethic of care is best illustrated when she/ he:a. uses touch to provide comfortb. provides a person- to- person encounterc. listens to clientsd. shows sensivity to unequal relationship

21. The nurse has a responsibility to perform nursing care activities based upon standards of practice. This means that:

a. minimum level of performance is accepted to ensure high quality careb. nursing action performed by the nurse is based on scientific knowledgec. nursing activities performed by the nurse to an acceptable leveld. practices observed by nurses ensure quality care

22. An elderly client in the Medical unit tells the nurse that he is tired of the treatment and sees no improvement and he would rather take all his medication to end his sufferings. Which of the following should be the initial action of the nurse?

a. assess the client and make appropriate referralsb. call the attention of the wife and watch the client closelyc. recommend to the client to seek advocacy supportd. communicate the client’s wishes to his family

23. A middle age client is frantic and upright. The client has an order of Benadryl 25 mg p.o. prn for itching. The nurse administered Benadryl. The best description for the nurse’s action is:

a. negligenceb. appropriatec. batteryd. malpractice

24. A female client has an order of repositioning every 2 hours. The nurse failed to change the position of the client as specified in plan of care. The nurses’ action constitutes a violation of:

a. Medical Practice Actb. Standardized Nursing Care Planc. Standards of Practiced. Nurse Practice Act

25. The nurse is taking care of an elderly client who is restless and tense. To protect the nurse from being sued for unlawful restraints which of the following should be her appropriate action?

a. tell the client that a restraint is to be applied for his own protection.b. Contact the physician for orders and document the reason for using restraintsc. Explain to the family that a restraint is needed for the protection of the clientd. Ask the family to be on the alert to protect the client from harming self

26. The nurse calls the physician to report a change in the condition of the client. The nurse is unable to reach the attending physician but left the message to his secretary. The secretary called back and relayed the verbal order of the physician. Which of the following is the MOST appropriate action of the nurse?

a. refuse to take the order from the secretaryb. accept the verbal order as it comes from the physician and record appropriatelyc. insist on talking to the physiciand. take a message and ask for the signature of the physician during the visit

27. A client is admitted with IV fluid due to severe diarrhea. While monitoring the flow rate of the client’s IV fluid, you assess his response to the treatment. The most important assessment that will show expected outcome for his client is:

a. daily weightb. presence of edemac. skin turgord. hourly urine output

28. You are administering 3 % Sodium Chloride solution to a client who has a diagnosis of Hyponatremia. Continous assessment is done to ensure that the client is safe from serious side effect of fluid volume excess. Your assessment will focus on the client’s:

a. pedal edemab. peripheral pulsesc. lung soundsd. urinary output

29. The nurse is taking care of a 45 year oldmale client with COPD. The client has difficulty raising respiratory secretions. Which of the following actions should the nurse perform to reduce the tenacity of the secretions?

a. encourage fluid intake from 2- 3 liters/ dayb. maintain client semi- fowler’s positionc. serve low salt, low fat dietd. administer O2 inhalation

30. The client asks the nurse why postural drainage is ordered by the physician. The nurse informs the client that this procedure is done to:

a. facilitate drainage after percussion has loosened the secretionsb. move secretions from lower to the upper segment of the lungsc. improve respiration by clearing the alveolid. help decongest the lungs through drainage of all lung segments.

31. The nurse kn ows that the principle used in postural drainage, cause the secretions to move through:a. force of gravityb. anterior to posterior lung segmentc. pleural space to the apical lung segmentd. sweeping motion during respiration

32. Oxygen administration at 2 L/ min through nasal cannula is prescribed for this client. When the client asks why he needs O2 therapy, your most appropriate response is that in his condition low oxygen level serves to:

a. balance CO2 contentb. act a stimulus for breathingc. restore normal breathing patternd. eliminate respiratory drive

33. The nurse teaches the client how to conserve energy. To meet this goal the nurse instructs the client to:a. blow slowly through purse lips when lifting objectsb. exhale then inhale with pursed lips when lifting objectsc. inhale then exhale with pursed lips when lifting objectsd. draw a deep breath through pursed lips when lifting objects

34. When he enters the room, he finds the client in bed. She says that she is “afraid to choke on her medications because sometimes she has hard time swallowing.” Which nursing action is most appropriate?

a. mix the medication in the client’s soupb. put the client in supine positionc. ask the client to assume sitting positiond. mix the capsule in a banana for her to chew

35. The nurse is going to instill otic drops to the client. He instructs the client to lie on his side opposite the ear to be medicated. To administer the otic medication the nurse will straighten the ear canal by pulling the pinna:

a. upward & forwardb. from side to sidec. upward and backwardd. downward and backward

36. When giving SQ injection to an obese client, the nurse should pinched the skin at site and inject medication at which angle?

a. 50˚b. 45˚c. 20˚d. 90˚

37. The nurse will next administer an IM injection preparation to another client. The nurse safely administers the drug using the Z track technique of injection for the following reasons EXCEPT:

a. this skin method leaves a zigzag path to seal the needle trackb. the skin is pulled sideways and the needle is injected at 45˚ anglec. this technique is best when medication for IM injection is irritating to tissued. this technique requires that the medication be injected slowly to allow it to disperse evenly in muscle

tissue

38. The nurse prepares Penicillin for skin test. He uses tuberculin syringe with gauge 25 needle and performs the procedure correctly by:

a. withdrawing needle quickly to minimize bleedingb. stretching skin over site and inserting needle at 10- 15˚ angle samplec. massaging the injection sited. pinching the skin over site and injecting medication slowly

39. A client is scheduled for surgery and the nurse infers from his body language that he is anxious. The nurse’s most therapeutic response would be:

a. “Think about healthy you could be after surgery”b. “I know how you feel. I had surgery before.”c. “If you are worried about the surgery, you shouldn’t. We have the best surgical team in the hospital.”d. “You seem worried. Would you like to talk about it?”

40. While talking to a 73 y/ o female client, the nurse notices that she does not have her hearing aid on. To ensure that the client can hear her, the nurse should:

a. speak aloud to client’s “good” earb. talk in high pitch voice slowlyc. enunciate and exaggerate her lip movementsd. speak slowly and distinctly and directly face the client

41. Which of the following steps should be included in reporting an incident?a. Record, investigate, notification, actionb. Notification, investigation, action and recordc. Investigate, report, action and record.d. Discovery, notification, investigation, consultation, action & record

42. Technology is an essential tool for all health service professionals. A computer based information system serves several purposes EXCEPT:

a. Build strategic resources for timely and relevant datab. Promotes organizational innovationc. Improve operational efficiency d. Use for decision making and communication

43. Of the following types of medication error, which error may reach the patient?a. dispensed wrong drugb. inability to administer right dosec. documented wrong dosed. prepared wrong dose

44. Which of the following is an organizational practice which may result to medication error?a. illegible hand writing of the physicianb. manufacturer’s labelling and packagingc. excessive workload for the staff nursesd. drug name confusion

45. The hospital set a patient safety goal to improve effectiveness of communication among the nurses. Which of the following strategies is related to this goal?

a. inform nurse of look-alike and sound-alike drugsb. use at least two patient identifiersc. provide preference guide to verify generic and brand names of drugsd. standardize abbreviations

46. Illegible handwriting of prescriber is a source medication error. Which of the following is a preventive measure related to this?a. have a pharmacist review medication ordersb. clarify order with the prescriberc. utilize medication administration scheduled. administer only fully labelled medications

47. The nurse found out that the medication she supposed to administer is not available in the patient’s cubicle. Which of the following is a safety practice to be followed by the nurse?

a. adjust schedule of drug administrationb. wait for the pharmacy to dispensec. skip the current dosed. borrow medication from another patient’s medication cubicle

48. In the hospital where you work, increased incidence of medication error was identified as the number one problem in the unit. During the brainstorming session of t the nursing service department, probable causes were identified. Which of the following is process related

a. Interruptionsb. use of unofficial abbreviationsc. lack of knowledged. failure to identify client

49. Miscommunication of drug orders was identified as a probable cause of medication error. Which of the following is a safe medication practice related to this?

a. maintain medication in its unit dose package until point of actual administrationb. note both generic and brand name of the medication in the Medication Administration Recordc. only officially approved abbreviations maybe used in the prescription ordersd. encourage client to ask question about their medications

50. An order for a client was given and the nurse in charge of the client reports that she has no experience of doing the procedure before. Which of the following is the most appropriate action of the nursing supervisor?

a. assign another nurse to perform the procedureb. ask the nurse to find a way to learn the procedurec. tell the nurse to read the procedure manuald. do the procedure with the nurse

51. Mr. Jose’s chart contains all information about his health care. The functions of records include all the following EXCEPT:a. means of communication that health team members use to communicate their contributions to the client’s health careb. the client’s record also shows a document of how much health care agencies will be reimbursed for their services

c. educational resource for student of nursing and medicined. recording of actions in advance to save time

52. An advantage of automated or computerized client care system is:a. the nursing diagnoses for client’s data can be accurately determinedb. cost of confinement will be reducedc. information concerning the client can be easily updatedd. the number of people to take care of the client will be reduced

53. Information in the patient’s chart is inadmissible in court as evidence when?a. the client’s family refuses to have it usedb. the client’s objects to its usec. the handwriting is not legibled. it has too many abbreviations that are “ unofficial”

54. Nursing audit aims to:a. provide research data to hospital personnel b. study client’s illness and treatment regimen closelyc. compare actual nursing done to established standardsd. provide information to health-care provider

55. A telephone order is given for a client in your ward. What is your most appropriate action?a. copy the order on the chart and sign the physicians name as close to his original signature as possibleb. repeat the order back to the physician’s , cop onto the order sheet and indicate that it is telephone orderc. write the order on the client’s chart and have the head nurse co- sign itd. tell the physician that you cannot take the order but you will care the nurse supervisor

56. Which of the following client conditions should be Miss Rogue’s priority in the pediatric unit?a. the baby whose fontanelle is bulging and firm while asleepb. the infant who is brought in for upper respiratory tract infection whose temperature is slightly elevatedc. a baby who is wailing after being awakened by the banging of the doord. a baby boy whose circumcision has yellowish exudates

57. When suctioning the endoctracheal tube, the nurse should:a. explain procedure to patient, insert catheter gently applying suction, withdrawn using twisting motionb. insert catheter unit resistance is met, then withdrawn slightly, applying suction intermittently as catheter is withdrawnc. hyper oxygenate client then insert catheter using back and forth motiond. insert suction catheter four inches into the tube, suction 30 seconds using twirling motion as catheter is withdrawn

58. As a nurse you were taught how to evaluate arterial blood gas (ABG) values. Which of the following do first?a. evaluate HCO3b. evaluate pHc. determine acid base statusd. evaluate PaCO2

59. For client’s with diabetic ketoacidosis, their body compensate for the acidosis in many ways. When caring for these clients, which of the following manifestations will you anticipate to observe?

i. Nausea and vomitingii. Oliguriaiii. Kussmaul breathingiv. Polyuria

a. 1 and 2b. 3 and 4c. 1,3 and 4d. all of the above

60. Brenda, 30 years old, was brought to the Emergency Department (ED) with nausea, confusion, dehydration and oliguria. Her mother informs you that Brenda has been depressed after loosing her jobs as a bank executive. An empty bottle of Aspirin was found in her bathroom sink. Her laboratory values revealed the following: pH=7.35, PaCO2=66,mmHg, PaO2=130 mmHg and HCO3=26mEq/L. What is the correct acid-base interpretation of her ABG?

a. Compensated respiratory acidosisb. Uncompensated metabolic acidosisc. Compensated metabolic acidosisd. Compensated metabolic acidosis

61. From the record of a client whose pulmonary artery pressure is being monitored through a pulmonary artery catheter, she encountered a report regarding right arterial pressure. Which of the following is an appropriate interpretation of right atrial pressure?

a. right ventricular end-systolic pressureb. indirectly reflects ventricular contractionc. reflects atrial filling from superior vena cavad. pressure in the atrium during ventricular filing

62. Which of the following symbols are used to document arterial oxygen saturation as measured by pulse oximeter?a. pO2b. paO2c. SpO2d. SO2

63. The ICU nurse orientee observed the following arterial blood gases results in one of the patient’s record: ph-7 46;paO2-97 mmHq;paCO2-40mmHg and HCO3-30meq/L. Which of the following is the interpretation of theses results?

a. respiratory alkalosisb. metabolic acidosisc. metabolic alkalosisd. respiratory acidosis

64. The ICU nurse orientee further observed that a liver biopsy which was scheduled for a patient was postponed. When she received the CBC and prothrombin time results of the patient, which of the following did she identify as the probable cause of the postponement of the liver biopsy?

a. Prothrombin time – 15 secondsb. plateletcount- 100,000/mm3c. Hemoglobin- 12gm/dld. Hematocrit 39%

65. A patient was admitted because of severe complication related to Stevens-Johnson Syndrome. The patient has red purplish lesions on the face, torso and mucous membrane. Which of the following is CORRECT about Stevens- Johnson Syndrome?

a. hypersensitivity reactionb. skin malignancyc. bacterial infectiond. viral infection

66. You were asked to attend a seminar on basic infection control where standard to client’s call. This type of quality evaluation is called. Your nursing action which indicates your observance of standard precautions would be when you:

a. dispose needles, scalpel blades, sharp instrument in double bagsb. protect yourself from infections through contact with blood or body fluid borne virusesc. protect yourself from contact with blood, open wounds and body fluidsd. practice frequent hand washing including washing of contaminated gloves

67. You have mild cough, runny nose and low fever but you still reported to work. Which of the following actions is NOT an effective way to control infection?

a. do frequent hand washingb. cover your mouth and nose when you sneeze or coughc. Minimize working with clients highly susceptible to infectionsd. Use mask, gloves and gown while working.

68. Understanding the risks of infection, who among the clients listed below should receive immediate attention and care?

a. Adult female with Vit. B deficiency due to chronic alcohol intakeb. Adult male with fresh second degree burns on arms and chestc. A teenager who is bleeding due to a cut on the fingerd. An elderly male with diabetes mellitus and toe infection

69. During the seminar the nurses are informed that ICU patients have a high risk of contracting hospital acquired infections. Which of the following explanations is TRUE?

a. Many procedures done in the ICU expose clients to more pathogensb. ICU is never empty so disinfection of this special area is difficult to accomplishc. Clients are critically ill and highly susceptible to infectiond. ICU personnel are less strict with asepsis since clients are on antibiotics all the time.

70. While taking care of clients, the nurse practices basic personal hygiene when she:a. Wears ornate jewelry to look pleasant to her clients and colleaguesb. Uses perfume to smell clean and fresh and avoid unpleasant body odorc. Uses light colored nail polish to protect her nails from infectious materiald. Fixes her hair so that does not fall to her face

SITUATION: The nurse in the Pediatric Unit is preparing medications for a child for surgery. His weight is 22. 9 kg. The physician ordered Atropine Sulfate 0.2 mg to be administered subcutaneously. An IV infusion of 0.9% Normal Saline solution 500 ml was stated to run for 24 hours.

71. In determining volume for subcutaneous injection for infants and small children, the nurse should be guided that the maximum amount is:

a. 1.5 mLb. 1 mLc. 0.5 mLd. 0.1 mL

72. The safe dose of Atropine Sulfate for children is 0. 01 mg/ kg. The nurse computed the safe dose for the prescribed Atropine Sulfate. She computed the correct dose if she obtained:

a. 0.4 mgb. 0.2 mgc. 0.1 mgd. 0.3 mg

73. After arriving at the safe dose of Atropine Sulafate, the nurse analyzes the desired dose ordered. Which of the following conclusions should guide the nurse in administering the drug?

a. desired dose is within safe dose rangeb. weight of child is not proportional to the desired dosec. desired dose is more or less adequate for the child’s weightd. computed dose is more than the desired dose

74. The nurse is using an IV infusion device for the intravenous Fluid. A total of 500 ml of 0.9 % NSS is to infuse over 24 hours. At what hourly rate should the nurse program the IV infusion device?

a. 21 ml/ hrb. 30 ml/ hrc. 41 ml/ hrd. 15 ml/ hr

75. The vital signs sheet of a client reads 104/ 100/ 90. The reading of “100” is interpreted appropriately as the pressure level when the:

a. 1st thumping sound is heardb. Sound becomes muffledc. Last sound is heardd. Sound has a whooshing quality

76. There is an order to obtain the patient’s arterial blood oxygen saturation (SaO2). What will you prepare to do the test?

a. pulse oximeterb. intravenous pumpc. spirometerd. ventilator

77. The equipment set an alarm and gave a reading of 69 % SaO2. When ask for initial action in the situation, you most appropriate response is to:

a. call the physician and report the reading immediatelyb. change the position of the clientc. check the connection of the equipmentd. assess the client’s vital signs

78. A client reported to have orthostatic hypotension. Which of the following would you consider a sign?a. Increase in pulse 0f 40 beats/ min and decrease in BP of 30 mm Hg from a sitting to a standing

positionb. A drop of 30 mm Hg from a supine to a standing position with a rise in pulse of 40 beats/ minc. Decrease in pulse by 20 beats/ min and increase in BP by 20 mm Hg from supine to standing

positiond. A sudden drop in BP of 30 mm Hg systolic and 10 mm Hg diastolic from lying to sitting or sitting to

standing position79. You demonstrate the correct technique in taking thigh blood pressure. Which of the following should you do

1st?a. Wrap the cuff around the mid- thighb. Help client assume a prone positionc. Expose the thighd. Locate the popliteal artery

80. When conducting assessment, the nurse is expected to obtain which of the following significant findings in pneumonia?

i. cough, fever and chest painii. cough and hypoxiaiii. dyspnea, tachypnea, tachycardiaiv. crackles and wheezes

a. 1 onlyb. 1 and 3c. 3 onlyd. 2 and 4

81. With the above data, the nursing diagnosis should be stated as:a. impaired oxygenation r/ t cough and shortness of breathb. impaired gas exchange r/ t presence of infectious exudate in the left lobe of the lungc. impaired oxygenation r/ t pneumonia with infectious exudate in the left lobe of the lingd. impaired circulation r/ t productive cough and pain in the left chest.

82. The nurse classified the nursing intervention for this client. Which of the following statements refers to this?a. circulatory status: adequate blood exchangeb. airway management: facilitation of patency of air passagesc. respiratory status: gas exchanged. demonstrates return of temperature to 37˚c

83. The nurse formulates plan of care with the client and states the expected outcome as:a. reports relief of dyspneab. expresses comfort of well beingc. speaks comfortablyd. improved breathing

84. The nurse instructs the client how to do effective coughing techniques. The expected outcome of this technique that will benefit the client is:

a. patent airwayb. increased clearance of exudatesc. adequate tissue perfusiond. improved breathing

85. Variations in sleep pattern in the different age groups are evident. Which of the following g is TRUE regarding sleep required among middle- aged group?

a. the satisfaction with the quality of sleep increases as one approaches the middle- age levelb. sleep and rest fluctuates in relation to job- related stress and parenting responsibilitiesc. the frequency of nocturnal awakening tends to increase while satisfaction with the quality of sleep

tends to decreased. cardian rhythm tends to be prominent with increasing age

86. The goal for the client is that he will:a. verbalize orientation to night and dayb. sleep more at night and less during the dayc. increase nocturnal sleepd. gain satisfaction from nocturnal sleep

87. Which of the following is the best time for the client to take a nap?a. time of day opposite to the midpoint of the nocturnal sleep periodb. time of day near the midpoint of the nocturnal sleep periodc. mid- morning and should be 30 minutes or lessd. mid- afternoon for at least 1 hour.

88. A 68 y/o female client is for discharge. The daughter asks the nurse what she could do to prevent injuries at home since the client has poor vision. You instruct the daughter to:

a. maintain position of furniture in the houseb. keep the house well lighted at all timesc. put the client on bed rest to prevent possible accidentsd. use wheelchair in the house

89. A 30 year old female client, states that she has frequent UTI and asked the nurse how she could prevent recurrence. Which of the following is the appropriate instruction of the nurse?

a. regaular intake of 2 glasses of apple juice dailyb. wear cotton underwear with pantyliners all the timec. drink eight ounce glasses of water dailyd. wipe perineal area after every voiding

90. An 8 y/ o is diagnosed with iron deficiency anemia. When assessing the child’s fingernails, the nurse instructed the mother to look for:

a. spoon nailb. pale nail bedsc. clubbingd. presence of Beau’s lines

91. A client is a heavy smoker consuming 4 packs daily. He asks the nurse why he can’t seem to quit smoking easily. Your best explanation is that nicotine:

a. is associated with a “cool” image of a young manb. affects mood and behaviour and causes tolerancec. decreases heart rate and respiratory rated. is in the body system for a long time and causes relaxation

92. When giving health teachings to people who are experimenting with cigarette smoking, the nurse explains the following problems caused by smoking EXCEPT:

a. smoking greatly increases risk for ischemic heart diseaseb. smoking is a major risk factor for cardiovascular problemsc. pregnant women can smoke without risk to fetusd. many types of cancer such as lung, oropharyngeal, laryngeal are related to smoking

93. A hospitalized client has an order for NGT feeding. Before starting the feeding you check if the tube is in place. The best way to do this is to:

a. reinsert a new NGTb. introduce 10- 15 ml of air and auscultate to listen to the gurgling soundc. aspirate gastric content and check the pH leveld. lower the tube and allow the secretions to drain then examine secretions

94. A client recovering from breast surgery asks you what type of food would fight “free radicals” to increase protection from cancer. Your best response would be:

a. “Do you want reading materials in cancer fighting food?”b. “Food rich in beta- carotene, vit. A, C, E seem to fight free radicals”c. “Eat food that are rich in antioxidants and phytochemicals”d. “Have you tried the herbal products in the market?”

95. You are taking care of a client who has weakness on the right side of the body. You assess that client has a high risk for aspiration while feeding. Your most appropriate nursing intervention when feeding the client would be to:

a. raise the head part of the bedb. feed clear liquid dietc. use strawd. place the food on the unaffected side of the mouth

96. The elderly are more at risk of nutritional deficiency and dehydration. While talking to a client who is for discharge, he tells you about how his plans to keep himself well nourished and hydrated. Which of the following statements by the client will indicate that he needs some health instructions from you?

a. “I don’t drink too much at night so I won’t have to wake up to go to the bathroom.”b. “I drink water or juice whenever I get thirsty”c. “At night, I eat less food and avoid coffee so I won’t go to the bathroom frequently”d. “I consume at least a glass of water or juice with every meal.”

97. The client says “being in the hospital makes me nervous.” The nurse’s most appropriate response would be to say:

a. “You feel nervous?”b. “Why? What about being in the hospital makes you nervous?”c. “It is normal to feel nervous. Is this your 1st time to be in a hospital?”d. “Don’t worry, nurses are on duty round the clock and they will help you.”

98. While talking about the loss of her husband a few months ago, the client becomes teary eyed and soon stops talking. The nurses’ most therapeutic response would be to:

a. tell the client that it is normal to be sad under such circumstancesb. leave the client so she can have some privacyc. change the topic conversation so she won’t feel sadd. remain silent, sit with the client

99. The client is informed that she has malignant breast cancer and has had radical mastectomy as soon as possible. The nurse finds her sobbing uncontrollably saying “I should have gone to the doctor sooner. Now my kids will grow up without a mother.” The nurse’s best therapeutic response would be:

a. :”You feel that if you had been diagnosed earlier things would be different?”b. “Don’t lose hope. Surgery and radiotherapy work wonders.”c. “It is natural to feel that way. Most clients do.”d. “Is your husband close to your children?”

100.Of the following preliminary tasks, which of the following should the researcher do to obtain available knowledge in her area of interest?

a. review literatureb. identify the populationc. state the problemd. select the variables