Week 10 Worksheet

Instruction: Choose the correct answer, then write your rationale or supporting statement from
your textbooks to the space provided:
Situation 1: Nurse Myka will administer medications to clients from various age groups and with
different health conditions.
1. When administering medications to an infant, Nurse Myka knows that one of the
following statements is CORRECT.
A. Mix the medication with orange juice to mask the unpleasant taste of medications.
B. Place a small amount of the liquid medication along the inside of the baby’s cheek
and wait for the infant to swallow before giving more medications.
C. Dilute the medications in lots of water to facilitate swallowing.
D. It is best to prop up the child in a chair when administering medications to avoid
struggling in the supine position.

Answer B.
Rationale:
To prevent aspiration. Oral Medications for children and infant are usually prepared in a
sweetened liquid form to make them more palatable. Do not use unneccesary foods such as milk
or orange juice just to mask the taste of the medications, because the child may develop
unpleasant associations and refuse that food in the future.
2. Nurse Myka is about to administer 0.5 ml of medication subcutaneously in the upper arm
of a 200-pound client. She can grasp approximately 2 inches of the client’s tissue at the
upper arm. Which among the following will nurse Myka use?
A. 2-ml syringe, gauge 25, 5/8-inch needle
B. 2-ml syringe, gauge 22, 1-inch needle
C. 1-ml syringe, gauge 23, 1 1/2-inch needle

Answer A.
Rationale:
The type of syringe for subcutaneous injection depends on the medication to be given. Generally,
a 2 mL syringe is used for most subcutaneous injections. Generally, a #20 to #23-gauge needle is
used for IM injections. Needle size and length are based on the client’s body mass, the intended
angle of insertion, and the site of the injection. Generally, a #25 - gauge, 5/8 - inch needle is used
for adults of normal weight and the needle is inserted at a 45- degree angle. Because 2 inches of
tissue can be grasped or pinched at the site of the injection, the nurse should administer the
medication at a 90 - degree angle to ensure the medication reaches subcutaneous tissue.
3. Nurse Daryll noted that Mr. Balinton’s 24 hour urine output amounted to 2,000 ml. This
is indicative of;
A. Normal amount of daily urine output
B. Increased amount of daily urine output
C. Decreased amount of daily urine output
D. Relatively an unusual amount of daily urine output

Answer: A.
Rationale:
An average adult produces 1-2 L urine per day. or the normal range for 24-hour urine volume is
800 to 2,000 milliliters per day (with a normal fluid intake of about 2 liters per day). 
Excessive urine output is called polyuria. Scantly urine output is oliguria. An output of less than
400 mL/day is insufficient to excrete toxic waste.
4. Nurse Maro would most like provide health teachings of taking ferrous sulphate to;
A. Grace, a client with an RBC = 4.2 x 10 6/mm
B. Anna, a client with haemoglobin = 16 g/dl
C. Stephanie, a client with haemoglobin = 11 g/dl
D. Kyla, a client with an RBC = 5.1 x 10 6/mm3

Answer: C.
Rationale:
Ferrous sulfate is an Iron supplement used to treat or prevent iron-deficiency anemia. In iron-
deficiency anemia, a lack of iron reduces production of hemoglobin. Hemoglobin allows red
blood cells transport oxygen around the body as well as giving red blood cells their color. Lower
than normal hemoglobin levels indicate anemia. The normal hemoglobin range is generally
defined as 13.5 to 17.5 grams of hemoglobin per deciliter of blood for men and 12 to 15.5 grams
per deciliter for women. An RBC count is measured in millions per cubic millimeter (mm 3)
Normal values may vary slightly among different laboratories. One example of normal values is
4.1 to 5.1 mm3 for women. Option A, B and D is within normal values while Option C is below
the normal values that’s why Nurse Maro, should provide health teaching for Stephanie, a client
with hemoglobin 11g/dl, about taking ferrous sulphate.
5. Nurse Jojo would assess for signs of hypomagnesemia in which of the following clients?
1- Client taking magnesium-containing antacids
2- Client with renal failure
3- Client with chronic alcoholism
4- Client with pancreatitis
5- Client with excessive NGT drainage
A. 1,2,3 C. 3,4,5
B. 2,3,4 D. 1,4,5

Answer. C.
Rationale:
Options 1 and 2 relate to hypermagnesemia
Situation: Nurse Anjo is assigned in the Recovery Room or Post Anesthesia Care Unit.
6. Nurse Anjo noticed that a semi-conscious patient is experiencing dyspnea. Which among
the following should Nurse Anjo perform first?
A. Place pillow under client’s head
B. Apply oxygen mask
C. Reposition the client to keep the tongue forward
D. Remove the oropharyngeal airway

Answer: C.
Rationale:
The tongue can obstruct the airway in a semi- conscious client. Re-positioning in the side-lying
position with the face slightly down will help prevent occlusion of the pharynx and also allow
the drainage of mucus out of the mouth. A pillow under the head increases the risk for airway
obstruction, actions to promote an open airway in place. The problem is obstruction, not the
percentage of available oxygen.
7. Nurse Anjo is reviewing interventions designed to promote client recovery and prevent
complications. All of the following are correct statements EXCEPT:
 A. Pain is greatest 12 to 36 hours after surgery and decreasing after the second and third
postoperative day.
B. Clients who have had spinal anesthesia should lie flat in bed for 8-12 hours
C. Place pillows under client’s knees to avoid rubbing against the bed linens.
D. Client should perform leg exercises every 1-2 hours during waking hours

Answer: C.
Rationale:
Option A, B, and D is the interventions to promote client recovery and prevent complications.
Option A: Pain is usually greatest 12 to 36 hrs. after surgery, decreasing after the second or third
postoperative day. Option B: Position the client as ordered. Client who have had spinal
anesthetics usually lie flat for 8-12hrs. An unconscious or semi-conscious client is placed on one
side with the head slightly elevated, if possible, or in a position that allows fluids to drain from
the mouth. Option D: Encourage the client to do leg exercise taught in the preoperative period
every 1 - 2 hrs during the walking hours. Muscle contractions compress the veins, preventing the
stasis of blood in the veins, cause of thrombus (stationary clot adhered to the wall of the vessel)
formation and subsequent thrombophlebitis (inflammation of the vein followed by formation of a
blood clot) and emboli (a blood clot that has moved). Contractions also promote arterial blood
flow. Avoid placing pillows or rolls under the client’s knees because pressure on the popliteal
blood vessels can interfere with blood circulation to and from the lower extremities.

8. One of the patients of nurse Anjo developed urinary tract infection in the postoperative
period. All of the following are ways on preventing urinary tract infection EXCEPT:
A. Providing ice chips C. Adequate fluid intake
B. Early ambulation D. Aseptic straight catheterization, as
needed

Answer: A.
Rationale:
Option A is an intervention for a patient with nausea and vomiting, Option B, C, D are
interventions to prevent urinary tract infections.
 9. Nurse Anjo wants to prevent pulmonary embolism in her clients. Which among the
following will prevent such a complication?
A. Fluid replacement C. Leg exercises
B. Turning the client D. deep breathing exercises and coughing

Answer: C.
Rationale:
Encourage leg exercises (such as flexion and extension of the feet, active contraction and
relaxation on calf muscles) for a client on bed rest, and promote ambulation as soon as possible.

10. Which among the following should NOT be delegated by Nurse Anjo to an unlicensed
assistive person?
A. Transfering the client with the use of a new wheelchair.
B. Assisting the transfer of an elderly client
C. Assisting the client to ambulate for the first time in surgery
D. None of the above

Answer: C.
Rationale:
A new postoperative client is, in a somewhat unstable condition and the nurse must assess,
observe and closely monitor the client and supervise this initial transfer. Age does not determine
need for assistance. The task is simple and can be easily recalled safely after an absence.
Situation: Leni, a 70 year-year-old patient had a fractured pelvis. Her family requests that they be
allowed to stay overnight in the hospital room.
11. The nurse assess Leni after surgery and finds that her pain is ranked as 3 in the pain
rating scale, her vital signs are within the preoperative range, and her extremities are
warm with good pulses, but with dry skin. Leni refuses oral fluids because of nausea and
reports no bowel movement in the past 2 days. Her hip dressing is dry with drains intact.
Which among the following nursing problems will be considered high priority?
A. Pain C. Constipation
B. Nausea D. Risk for wound infection

Answer: A.
Rationale:
Pain is an unpleasant and highly personal experience that may be imperceptible to others, while
consuming all parts of the person’s life. The widely agreed-upon definition of pain is “an
unpleasant sensory and emotional experience associated with actual or potential damage, or
described in terms such damage” (American Pain Society [APS], 200; Gordon. 2002). is more
than a symptom of a problem; it is a high priority problem itself. Pain presents both physiologic
and psychologic dangers to health and recovery. Severe pain is viewed as an emergency situation
deserving attention and prompt professional treatment.
12. Leni also has ineffective airway clearance as a nursing diagnosis. Which among the
following statements regarding prioritization of nursing problems is INCORRECT?
A. Nursing diagnosis related to airway problem represents life-threatening problems,
thus often of highest priority.
B. If the airway problem is in the process of improving, other diagnoses may become
higher priority.
C. It is not necessary to resolve all high priority diagnoses before addressing others
D. None of the above

Answer: C.
Rationale:
Airway must given the first attention as based on the rule of ABC which is Airway, Breathing
and Circulation. In addition, difficulty of breathing can cause anxiety to the client that is why,
immediate attention must be done. Addressing the problem to proper health care provider will
give patient patent airway to the client. Oxygenation is a vital need for every cell, if there are any
problems related to it can easily affect the functioning of the individual. Retained secretions can
cause blockage of airway which will further cause difficulty of breathing.
13. The nurse also identified the nursing diagnosis as Risk for Impaired Skin Integrity related
to immobility, dry skin and surgical incision. Which of the following represents a
properly stated outcome or goal?
A. The client will turn in bed every 2 hours.
B. The client will report the importance of applying lotion to the skin daily
 C. The client will have intact skin during hospitalization
D. The nurse will use a pressure-reducing mattress on the client

Answer: A.
Rationale:
Encourage the client to turn from side to side at least every 2 hrs. Turning alternates which lung
can achieve maximum expansion because it is the uppermost. Avoid placing pillows or rolls
under the client’s knees because pressure on the popliteal blood vessels can interfere with blood
circulation to and from the lower extremities. Clients who practice turning before surgery find it
easier to do after surgery. The client should ambulate as soon as possible after surgery in
accordance with the surgeon’s orders. Generally, client begin ambulation the evening of the day
of surgery or the first day after surgery, unless contraindicated. Early ambulation prevents
respiratory, circulatory, urinary, and gastrointestinal complications.

14. The nurse noted that the physician had an order of diet as Tolerated for Leni. What type
of nursing intervention is this?
A. Independent intervention C. Collaborative intervention
B. Dependent intervention D. None of these

Answer: B.
Rationale:
Dependent nursing intervention are those that require an order from other health care
professional. Option A: Independent nursing intervention are those sanctioned by professional
nurse practice acts. They do not require direction or an order from another health care
professional. Collaborative nursing intervention area actions that are implemented in a
collaboration or consultation with other health care professionals.
Situation: Ellen, a 61-year-old client has arrived to the nursing unit from surgery.
15. The nurse would most like give priority to which of the following assessments?
A. Vital signs C. Location of the pain
B. Pain intensity D. Frequency of pain

Answer: B.
Rationale:
In a postoperative client, the most important nursing intervention is to assess pain intensity
frequently to manage the acute pain experience. Options A and C are also appropriate but you
need to assess the client’s pain intensity for effective pain management. Option C: Location of
pain is important, but you need to know the client’s pain intensity first for effective pain
management. Option D: This information is important but not for a client in acute pain. The
priority would be to assess the pain intensity. Clients in acute pain may not want to answer pain
history questions. You can ask when they are more comfortable.
16. The nurse assessed Ellen for pain. Which statement reflects this?
A. Do you have any complaints?
B. Could you describe if you are feeling any discomfort right now?
C. Is there anything I can do for you?
D. Are you experiencing pain?
Answer: B.
Rationale:
The words “pain” or “complain” may have emotional or sociocultural meanings. It is better to
ask clients if they are having any discomfort - they can then elaborate in their own words. Option
C is too general and expects clients to report their pain without being asked.
17. When planning for pain management in aging clients like Ellen, the nurse should apply
which principle?
A. Sensitivity to pain increases with age
B. Pain is a normal outcome of the aging process.
C. Older persons may deny the pain.
D. The nurse should avoid the use of narcotics in the elderly.
Answer: C.
Rationale:
Older clients may withhold complaints of pain because it may indicate a worsening of their
condition that may threaten their independence. Elders may describe pain differently - using
words other than “pain”. Although many perceive pain as a natural outcome of aging, pain is not
a natural part of aging. Pain perception may decrease and narcotics can be used with careful
monitoring by the nurse.
 18. The nurse knows that the single and most important indicator of the existence and intensity
of pain is:
A. BP = 140/90 mmHg, PR = 80 per minute C. Client is moaning and crying

B. Client doubles up and grimaces D. Client rates the pain as a 7

Situation: Mrs. Fernandez, a 41 year old bank teller reports weakness, malaise and flu-like
symptoms for 3-4 days. Although thirsty, she is unable to tolerate fluids because of nausea and
vomiting and she has liquid stools 2-4 times per day. Upon further assessment, the client was
noted to have T = 38.7 degrees celcius, RR = 25 per minute, BP = 100/80 mmHg, scant urine
output, dry oral mucosa, furrowed tonge and cracked lips.
19. Mrs. Fernandez appears lethargic and is complaining of leg cramps. Which of the
following should the nurse do first?
A. Start an IV C. Review the results of serum electrolytes
B. Offer foods that are high in Na and K D. Administer anti-emetic
Answer: C.
Rationale:
Further assessment is needed to determine appropriate action. While the nurse may perform
some of the other interventions, assessment is needed initially. And Electrolyte test.
An electrolyte test can help determine whether there's an electrolyte imbalance in the
body. Electrolytes are salts and minerals, such as sodium, potassium, chloride and bicarbonate,
which are found in the blood. They can conduct electrical impulses in the body.
20. Mrs. Fernandez is responding inappropriately to the nurse questions. She seems to be
confused. What is causing her neurologic symptoms?
A. Disorientation C. Intracellular dehydration
B. Sedation D. Aging
Answer: A.
Rationale:
She has an altered mental state so she is responding inappropriately to the nurse which is
disorientation.
21. What action should the nurse take first if Mrs. Fernandez heart rate becomes irregular?
A. Repeat the assessment C. Record the assessment
B. Start an IV infusion immediately D. Notify the physician

Answer: D.
Rationale:
Report to the primary care provider or Notify the physician any abnormal findings such as
irregular rhythm, and reduced ability to hear the heartbeat, pallor, cyanosis, dyspnea,
tachycardia, or bradycardia.
22. Which of the following statements of Mrs. Fernandez indicates the need for further
teaching regarding treatment for hyperkalemia?
A. I will take my potassium in the morning after breakfast.
B. I will increase my avocado intake.
C. I will stop using my salt substitute.
D. I will check my heart rate first before taking my digoxin.
Answer: C.
Rationale:
Salt substitutes contain potassium. The client can still use it within reason. Avocado is higher in
potassium than most foods. Hypokalemia can potentiate digoxin toxicity and checking the pulse
will help the client to avoid gastric upset.
23. Mrs. Fernandez asks the nurse why she weighs her every morning. The most appropriate
explanations of the nurse will be?
A. Weighing is an easy and quick way to get information about fluid balance.
B. Weighing gives information about her nutritional status.
C. Daily weight taking is part of the routine assessment.
D. Daily weight taking was ordered by the physician.
Answer: A
Rationale:
Rapid changes in your weight can mean you are gaining or losing fluid. Weighing yourself daily
at the same time every morning - and keeping a record will help you and your health care
providers to know about the specific status of the patient about fluid balance.
Situation: Nurse Isabel is assigned to Mercy, a 30 year old pregnant client with an order of NGT
feeding.
24. Prior to feeding, Nurse Lorena checks for the placement of the NGT. Which of the
following is the best indication of proper placement of the NGT in the stomach?
A. X-ray C. Fluid is easily instilled
B. pH of less than 5 D. Gurgling sound is heard when air is instilled into the
NGT.
Answer A.
Rationale:
Nurse Lorena can verify the placement of the tube by performing two of the following methods:
ask the patient to hum or talk (coughing or choking means the tube is properly placed); use an
irrigation syringe to aspire gastric contents; chest X-ray. To confirm the chest x-ray view should
be adequate upper esophagus down to below the diaphragm. Therefore X- ray is the best
indication of proper placement of the NGT in the stomach.
25. Mercy’s NGT has been attached to a suction machine for two 2 days. His input and output
record shows greater output than input. Which nursing diagnoses are appropriate in this
condition?
1. Decreased cardiac output 4. Impaired Oral Mucous Membrane
2. Deficient fluid volume 5. Risk for deficient Fluid volume
3. Impaired gas exchange
A. 1,3,5 C. 1,2,4
B. 2,3,4 D. 3,4,5
Answer: C.
Rationale:
Options 1,2, and 4 relate to fluid volume deficit. The data indicate the actual problem which
excludes option 3 relates more to fluid volume excess.
26. Nurse Isabel implements gravity tube feeding. Which among these is the proper technique
for gravity tube feeding?
A. Place the client in the left side lying position.
B. Feeding should be administered directly from the refrigerator
C. Nurse administers the feeding only if there is less than 50 ml of residual feeding.
D. Feeding bag is hung 1 foot higher than the tube’s insertion point in the client.
Answer: D.
Rationale:
For proper flow, the feeding container hangs 1 foot above the tube insertion. Feedings may be
administered if there is less than 90 to 100 ml of residual volume (unless agency policy specifies
otherwise) To prevent or reduce the risk of aspiration, the client should be placed in Fowler’s
position during feeding. The feeding should be warmed to room temperature before
administration to decrease cramping and diarrhea.
27. If Mercy suffers suffers from hypocalcemia, Nurse Lorena’s interventions should focus on
which system?
A. Renal C. Cardiac
B. Neuromuscular D. Gastrointestinal
Answer: B.
Rationale:
The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular
activity.
28. Mercy’s NGT is now removed. Nurse Daniel aims to increase Mercy’s calcium, iron and
fiber intake. Which of the following meals would she recommend to Mercy?
A. 3 oz of tuna plus 1 oz cheeze sandwich on whole wheat bread plus pear.
B. 1/2 cup broccoli, 3 oz of chicken, 1/2 cup peanuts.
 C. 1/2 cup spaghetti with 2 ounces ground beef and 1/2 cup lima beans plus 1/2 cup ice cream.
D. 3 ounces cottage cheese, 1/3 cup raisins, 1 banana
Answer: A.
Rationale:
3 ounces tuna + 2 slices whole wheat bread = 3.1 mg Fe; 1ounce cheese = -200 mg Ca ++; pear
= 4.2 gm fiber. Option B: 3 ounces chicken + 1/2 cup peanuts = 2.9 gm Fe; 1/2 cup broccoli =
-158 mg Ca ++; 1/2 cup broccoli = 2.4 gm fiber. Option C: 1/2 cup spaghetti + 2ounces ground
beef = 2:3 mg Fe; 1/2 cup ice cream = 97 mg Ca + +; 1/2 cup lima beans = 3.2 gm fiber. Option
D: 1/3 cup raisins = 1.75 mg Fe; 3 ounces cottage cheese= 90 mg Ca + +; 1 banana = 2.1 gm
fiber.
God bless!
2 Timothy 2:15 Study to shew thyself approved unto God, a workman that needeth not to be
ashamed rightly dividing the word of truth.