Professional Documents
Culture Documents
D. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion
18.The nurse knows that which of the following patients is most at risk for complications of the feet?
A. A young man in a career that requires standing
C. A 60-year-old person with diabetes mellitus
B. A disoriented, elderly man
D. A 62-year-old patient with total hip replacement
19.Mr. Javellana is an 82-year-old who is unconscious and requires meticulous oral hygiene. The optimal position for providing
oral hygiene to Mr. Javellana is the:
A. High-Fowlers position
C. Supine with head lowered
B. High-Fowlers position with head hyperextended
D. Side-lying position with head lowered
SPECIMEN COLLECTION OF DIAGNOSTIC EXAMINATION
20.A sputum specimen has been ordered for Mr. Buenaventura, a 75-year-old patient admitted with possible pneumonia of the
right lower lobe. Mr. Buenaventura is not able to cough. The nurse is aware that for patients who cannot expectorate sputum
from deep in the bronchial tree, the specimen must be collected by:
A. Pharyngeal suctioning B. Tracheal suctioning C. Oropharyngeal suctioning D. Percussion and vibration
21.The physician has ordered a stool specimen for blood that cannot be seen by the naked eye. This examination is for:
A. Profuse bleeding B. Gross blood
C. Melena D. Occult blood
22.Mr. Lagman, age 46, is seen by the physician for recurrent symptoms of cystitis. He is to have a urine culture and sensitivity
determination and a 24- hour urine collection for laboratory analysis. Mr. Lagman should be informed that a urine culture study
is required to:
A. Identify the causative organism
C. Analyze the elements present in the urine
B. Determine the presence of malignant cell
D. Localize the site of the inflammatory process
23.To obtain a 24-hour urine specimen, the patient should be given which of the following instructions?
A. Collect each voiding in separate containers for the next 24 hours
B. Discard the first voided specimen and then collect the total volume of each voiding for 24 hours
C. For the next 24 hours, retain a 30ml specimen
of each voiding after recording the amount voided
D. Keep a record of the time and amount of each voiding for 24 hours
24.Ms. Cristobal, age 72, has an indwelling urinary catheter. A sterile urine specimen has been ordered for a culture and
sensitivity. The sterile specimen should be obtained by:
A. Obtaining 60 ml of urine from the collection bag
B. Removing the present catheter, having the patient void, and then recatheterizing
C. Disconnecting the tubing from the catheter and draining 2 ml of urine
D. Aspirating 10 ml of urine with a sterile syringe from the tubing port
25.A patient performing a finger stick for blood glucose determination asks why the side of the fingertip is advised as the
preferred site. The nurse is aware that it is because:
A. The blood supply is greater in this area
C. The side of the finger is less responsive to pain
B. It is easier for the self-determination method
D. It leaves more room for other site selection
26.A patient is scheduled for an upper GI series and a barium enema. The nurse explains that because of the procedure for an
upper gastrointestinal study and barium enema, the patient can expect to:
A. Be NPO after midnight and have enemas until clear
B. Have coffee and toast the morning of the test
C. Take radiographic dye tablets
D. Have a needle inserted into the liver area
27.The patient tells the nurse, I have a very hard time getting a drop of blood from my finger for the blood sugar test. The
nurse:
A. Asks the physician to order a different type of blood glucose monitoring system
B. Suggests that the patient use warm water on the finger just before using the blood lancet
C. Instructs the patient to use the same puncture site several times in a row for best results
D. Reminds the patient that it is acceptable to skip blood glucose monitoring once in a while
SELECTED NURSING SKILLS
28.The nurse would use which of the following methods to determine the correct distance to insert a nasogastric tube?
A. Center of forehead to top of nose to end of sternum
B. Tip of nose to tip of earlobe to end of sternum
C. Lips to tip of ear to just below the umbilicus
D. Tip of ear to midway between end of sternum and umbilicus
29.After inserting a nasogastric tube, the nurse can be certain it is in the proper place if:
A. The patient no longer complains of pain or nausea
B. 30 ml of normal saline can be injected with ease
C. Bubbles occur when the tube is submerged into water
D. Gastric contents are aspirated with cone tipped syringe
30.Mr. Aragon, diagnosed with throat cancer, is a 2-day postoperative
patient with a tracheostomy. Which
part of
the tracheostomy tube is removed by the nurse for cleaning?
A. Outer cannula B. Inner cannula C. Single-lumen tube D. Double-lumen tube
31.What safety precaution must be taken for Mr. Aragon because he has a tracheostomy tube?
A. Keep a crash cart in the room
C. Keep curved hemostat at the bedside
B. Be prepared to put him on a ventilator
D. Be prepared to remove the tube
32.If, when suctioning Mr. Aragon, the nurse finds it necessary to repeat the interventions, it is recommended that the nurse wait
at least 3 minutes. This is to allow for:
A. Overcoming fatigue B. Numbing of mucous membranes C. Replenishing oxygen D. Subsiding of pain
33.Preoperatively the physician orders enemas until clear. The maximum number of enemas the
nurse should give is:
A. Snellen chart B. Cover-uncover test C. Corneal light reflex test D. Cardinal positions of gaze
53. The red reflex seen during an ophthal - moscope examination is the result of:
A. An increase in intraocular pressure
C. Light from the scope reflecting back from the choroids
B. Incorrect adjustment of the diopter
D. Anterior narrowing
54. Compared with the size of a childs pupils, the size of an adults pupils is:
A. Smaller B. Larger C. The same throughout life D. Wider
55. Before inserting the otoscope into the patients ear,
the nurse should palpate the;
A. Helix B. Earlobe C. Lymph nodes D. Tragus
56. During an otoscopic examination, the nurse should pull the superior posterior auricle of an adult patients ear:
A. Up and back B. Up and forward C. Down and back D. Straight back
57. Your patients complains of lower abdominal pressure, and you note a firm mass extending above the symphysis pubis. You
suspect:
A. A distended bladder B. An enlarge kidney C. A UTI D. An inflamed ovary
58. Your patient reports a 32-day menstrual cycle. You know this cycle is probably:
A. A normal variation B. A sign of metrorrhagia C. A precursor to uterine cancer D. A precursor to menopause
59. Your 76-year-old patient is diagnosed with iron deficiency anemia. What would you expect to find when assessing her nails?
A. Dark, yellowish nails
C. White patches on the nails
B. Transverse bands of white covering the nails
D. Spoon-shaped nails
60. You assess a childs visual acuity using the Snellen chart. The result is 20/50 in both eyes. Which explanation should you
give to her parent?
A. What normal eyes see at a distance of 50 feet, your childs eyes see at a distance of 20 feet.
B. What normal eyes see at a distance of 20 feet, your childs eyes see at a distance of 50 feet.
C. To see what the normal eye sees at a distance of 20 feet, your childs eyes need a 50% magnification increase.
D. Your childs eyes see 20% of what children with normal vision see at 50 feet
61. Electrocardiogarphy (ECG) is a diagnostic tool used to evaluate the electrical activity of the heart. Which of the following
ECG results would reveal that there is myocardial ischemia?
a. ST segment elevation and peaked T wave
c. ST segment depression and peaked T wave
b. ST segment elevation and inverted T wave
d. ST segment depression and abnormal Q wave
62. A client received digoxin (Lanoxin) therapy o treat the irregular beating of his heart. The nurse knows that the therapy has
been effective when the client with atrial fibrillation has an ECG tracing showing:
a. A heart rate of 50 beats per minute
c. A heart rate of 105 beats per minute
b. Mobitz II heart block
d. A heart rate of 70 beats per minute
63. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalvas maneuver?
a. Use of stool softeners.
c. Gagging while toothbrushing.
b. Enema administration
d. Lifting heavy objects
64. The nurse knows the client understands the teaching concerning a low-fat, low cholesterol diet when the client selects which
meal?
a. Fried fish, garlic mashed potatoes, and iced tea.
c. Baked chicken, baked potato, and skim milk.
b. Ham and cheese on white bread and whole milk.
d. A hamburger, French fries, and carbonated beverage
65. Cardiac magnetic resonance imaging (MRI) is prescribed for a client. The nurse identifies that which of the following is a
contraindication for performance of this diagnostic study?
a. Client has a pacemaker.
c. Client has diabetes mellitus.
b. Client is allergic to iodine.
d. Client has a biological porcine valve.
66. A client with angina has a 12-lead electrocardiogram taken during an episode of chest pain. A nurse examines the tracing for
which electrocardiographic change caused by myocardial ischemia?
a. Tall peaked T waves
c. Widened QRS complex
b. Prolonged PR interval
d. ST segment elevation or depression
67. An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include
when the patient has completed the test?
A. Stool will be yellow for the first 24 hours post-procedure.
B. The barium may cause diarrhea.
C. Fluids must be increased to facilitate the evacuation of the stool.
D. This series includes analysis of gastric secretions.
68. The most common adverse effects f long-term, high dose aspirin use are:
A. Nausea and skin rash
C. Tinnitus and gastrointestinal bleeding
B. Excessive thirst and vomiting
D. Dizziness and sedation
69. The correct sequence for an abdominal assessment is:
A. Inspection, percussion, palpation, and auscultation
C. Inspection, auscultation, percussion, and palpation
B. Percussion, auscultation, inspection, and palpation
D. Auscultation, inspection, palpation and percussion
70. Hyperactive bowel sounds may be a sign of:
A. Ileus or bowel obstruction
C. Constipation, diarrhea or laxative use
B. Peritonitis or opioid analgesic use
D. Diminished peristalsis
71. When administering a bolus gastrostomy feeding, the receptacle should be held no higher than
A. 9 inches.
B. 18 inches.
C. 27 inches.
D. 38 inches.
72. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions.
The nurse on assessing this data, can assume that the client is experiencing:
A. A reaction formation to his recent altered body image.
B. A difficult time accepting reality and is in a state of denial.
C. Impotency due to the surgery and needs sexual counseling
D. Suicide thoughts and should be seen by psychiatrist
73. The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the
colostomy will be
A. solid
B. mushy C. semi-mushy D. fluid
74. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
A. Abdominal cramps during fluid inflow
C. Passage of flatus during expulsion of feces
B. Difficulty in inserting the irrigating tube
D. Inability to complete the procedure in half an hour
75. A problem unique to the patient with an ileostomy is that
A. regular bowel habits cannot be established.
C. skin excoriation can occur.
B. sexual activity is restricted.
D. the collecting appliance is bulky and large.
76.What is the maximum length of time the nurse allows an IV bag of solution to infuse into the client?
A. 6 hours
B. 12 hours
C. 18 hours D. 24 hours
77. What clinical indicator will the nurse most likely identify when assessing a client with pyrexia?
A. Dyspnea
B. Precordial pain C. Increased pulse rate D. Elevated blood pressure
78.Poor oxygenation of the blood ordinarily will affect the pulse rate and cause it to become:
A. Bounding
B. Irregular C. Faster than normal D. Slower than normal
79.During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The
nurses actions are to:
A. Stop the installation
C. Stop the installation and obtain vital signs
B. Slow down the rate of installation
D. Tell the client to breath slowly and relax
80.The nurse is assessing a 55-year-old client who is in the clinic for a routine physical. The nurse instructs the client to obtain
fecal occult blood testing (FOBT):
A. When there is a family history of polyps
B. If client reports rectal bleeding
C. If a palpable mass is detected on digital examinations
D. As part of a routine examination for colon cancer
81.For a hearing-impaired client to hear a spoken conversation, the nurse should:
A. Approach a client quietly from behind
B. Face the client when speaking, use a louder than normal tone of voice
C. Select a public area to have a spoken conversation
D. Face the client when speaking; speak slower and in a normal volume
82.Sensory deficits happen when a problem with sensory reception or perception occurs. As a result clients may:
A. withdraw socially to cope with the loss
B. Rely solely on one sense
C. Respond normally to stimuli
D. Function safety within their environment
83.The urine appears concentrated and cloudy because of the presence of white blood cells or:
A. Bacteria
B. Urinary drainage bags
C. Blot clots D. Poor perineal hygiene
84.Maintaining a Foley Catheter drainage bag in the dependent position prevents:
A. Urinary reflux B. Urinary retention C. Reflex incontinence D. Urinary incontinence
85.When applying a condom catheter, it is important to secure the catheter in the penile shaft in such a manner that the catheter
is:
A. Tight and draining well
B. Dependent and draining well
C. Secured with adhesive tape applied in a circular pattern
D. Snug and secure, but does not cause constriction to blood flow
86.During the nursing assessment the client reveals that he has diarrhea and cramping every time he has ice cream. He attributes
this to the cold nature of the food. However, the nurse begins to suspect that these symptoms might be associated with:
A. Food allergy
C. Lactose intolerance
B. Irritable bowel
D. Increased peristalsis
87.A terminally ill client is visited frequently by her spouse, a 16-year-old daughter, and a 20-year-old son. In view of the
clients extreme weakness and dyspnea, the clients nursing plan of care should include:
A. Allowing self-activity whenever possible
B. Encouraging family members to assist with caring for the client
C. Limiting family visiting hours to the evening before the client sleeps
D. Planning necessary care at one time with long rest periods between care
88.A client who is in constant pain and undergoes frequent monitoring of vital signs is at risk for experiencing sensory:
A. Deprivation
C. Overload
B. Deficits
D. Stimuli
89.A nurse educator is presenting information about the Nursing Process to a class of nursing students. The nurse educator
states that the Nursing Process can best be defined as the:
A. Implementation of client care by the nurse
B. Steps the nurse employs to meet client needs
C. Activities a nurse employs to identify a clients problem
D. Process the nurse uses to determine nursing goals for the client
90.To utilize the Nursing Process, the nurse must first:
A. Identify goals for nursing care
C. Obtain information about the client
B. State the clients nursing needs
D. Evaluate the effectiveness of nursing action
91.The main reason that auscultation proceeds palpation of the abdomen is to:
A. Prevent distortion of vascular sounds
B. Prevent distortion of bowel sounds
C. Determine any areas of tenderness or pain