POWERHOUSE TRAINING &

REVIEW CENTER

FUNDAMENTALS OF NURSING
Mastery Exam 1
1. During a home visit, the nurse discusses health care concerns with the client and
establishes mutual goals to help the client become more independent. In this role,
the nurse is functioning as:

A. A researcher

B. A resource linker

C. An advocate

D. A collaborator
2. A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She
encourages them to participate in the unit’s decision making process and helps them
improve their clinical skills. This nurse is functioning effectively in which role?

A. Manager

B. Autocrat

C. Leader

D. Authority
 3. A primary care provider’s orders indicate that a surgical consent from needs to be
signed. Since the nurse was not present when the primary care provider discussed the
surgical procedure, which statement best illustrates the nurse fulfilling the client advocate
role?

A. “The doctor has asked that you sign this consent from

B. “Do you have any questions about the procedure?”

C. “What were you told about the procedure you are going have?”

D. “Remember that you can change your mind and cancel the procedure.”
 4. Which client behavior best demonstrates effective teaching?

A. Exhibiting a positive change in behavior

B. Verbally repeating the instruction

C. Making statements indicating that the client understands

D. Exhibiting nonverbal signs such as nodding the head to indicate

“yes”
5. Which strategy can help make the nurse a more effective
teacher?

A.Including the client in the discussion

B.Using technical terms

C.Providing detailed explanations

D.Using loosely structured teaching sessions

6. In Benner’s theory, From Novice to Expert: Expertise and Power in Clinical Nursing
Practice, nursing practice encompasses the five levels of proficiency. According to this
theory, the characteristic that separates an “expert” nurse from those lower levels of
proficiency is:

A. The ability to organize.

B. An advanced educational preparation.

C. An intuitive understanding of situations.

D. The ability to understand situations holistically.

 7. Which finding obtained during an assessment is considered
significant enough to require immediate communication to another
member of the health care team?

A.Change in a patient’s heart rate from 72 to 80

B.Diminished breath sounds in a patient with previously normal breath

sounds

C.Relief noted by a patient from prescribed nausea medication

D.Weight loss of 2 lb (1kg) in a 115-lb (52-kg) female patient

 8. A client comes to the emergency department complaining of a fast and irregular
heartbeat. After examining the client, the physician give a verbal order for digoxin
(Lanoxin) 1 mg I.V. in four divided doses over the next 24 hours, starting with the first
dose stat. How should the nurse respond to this order?

A. Write and sign the order as dictated, and then repeat it aloud for the physician’s
verification.

B. Verbally repeat the order to the physician for verification.

C. Insist that the physician write the order; then administer the drug.

D. Refuse to carry out the order.

  
9. The nurse has made an error in documenting an assessment finding on a
client and obtains the client’s record to correct the error. The nurse corrects the
error by:

A.Documenting a late entry in to the client’s record.

B.Trying to erase the error for space to write in the correct data.

C.Using correction tape to delete error to write the correct data

D.Drawing one line through the error, initialing and dating the line, and then
documenting the correct information
10. When obtaining client’s history, the nurse takes which
step?

A.Asks questions about the client’s reason for seeking care

B.Palpates the client’s abdomen

C.Auscultates for the client’s breath sounds

D.Documents medication administered

11. The client’s clinical impression is Pneumonia and is now on his
third day of confinement. The nurse prepares his plan of care
including discharge plan. When should discharge planning
commence?

A.24 hours after discharge

B.The day before discharge

C.Upon admission

D.When the patient desires

 12. What is a common goal of discharge planning in all care
settings?

A.Prolonging hospitalization until the client can function

independently

B.Teaching the client how to perform self-care activities

C.Providing the financial resources needed to ensure proper care

D.Preventing the need for medical follow-up care

13. A client is suffering from diabetic ketoacidosis and the nurse documents
that the client is experiencing Kussmaul’s respirations. Based on this
documentation, which of the following did the nurse observe?

A. Respirations that cease for several seconds

B. Respirations that are regular but abnormally slow

C. Respirations that are labored and increased in depth and rate

D. Respirations that are abnormally deep, regular and increased in rate

 14. The nurse measures a client’s apical pulse rate and compares it
with the radial pulse rate. The differential between these two pulses is
called:

A.The pulse pressure

B.The pulse deficit

C.The pulse rhythm

D.Pulsus regularis
  
15. To avoid recording an erroneously low systolic blood pressure because of failure to rcognize an
auscultatory gap, the nurse should:

A. Have the client lie down while taking his blood pressure.

B. Inflate the cuff to at least 200 mmHg

C. Take blood pressure readings in both arms

D. Inflate the cuff at least another 30 mmHg after the radial pulse becomes unpalpable.
 16. When auscultating the blood pressure, the nurse hears the
following: from 200 mmHg to 180 mmHg, silence; then, a thumping
sound continuing down to 150 mm Hg; muffled sounds continuing
down to 130 mm Hg; soft thumping sounds continuing down to 105
mmHg; muffled sounds continuing down to 95 mmHg; then silence.
The nurse records the blood pressure as:
A.150 / 95 C. 180 / 95
B.180 / 105 D. 150 / 105
17. A nurse performs a physical assessment on a client
and gathers both subjective and objective data. Which of
the following would the nurse documents as subjective
data?
A.Temperature is 37 degrees Celsius
B.Client reports difficulty sleeping at night
C.Pedal pulses are present
D.Client has an apical pulse rate of 56 beats/min
18. During physical examination, the nurse uses various techniques to assess
structures, organs and body systems. Which technique allows the nurse to
feel for vibration and locate body structures?

A. Auscultation

B. Inspection

C. Palpation

D. Percussion
 19. A client with fever, weight loss, and watery diarrhea is being admitted to
the facility. While assessing the client, a nurse inspects the client’s abdomen
and notices that it’s slightly concave. Additional assessment should proceed
in which order?

A. Auscultation, percussion and palpation

B. Palpation, percussion and auscultation

C. Percussion, palpation and auscultation

D. Palpation, auscultation and percussion

20. When auscultating a client’s abdomen, the nurse detects high-pitched
gurgles over the lower right quadrant. Based on this finding, the nurse
suspects:
A. Decreased bowel motility

B. Increased bowel motility

C. Nothing abnormal

D. Abdominal cramping
  
21. The nurse is assessing a client’s abdomen. Which finding should the
nurse report as abnormal?

A. Dullness over the liver

B. Bowel sounds occurring every 10 seconds

C. Shifting dullness over the abdomen

D. Vascular sounds heard over the renal arteries

22. When should the nurse check a client for rebound tenderness?

A. Near the beginning of the examination

B. Before doing anything else

C. Anytime during the examination

D. At the end of the examination

23. A client comes to the clinic for routine check-up. To assess the client’s
gag reflex, the nurse should use which method?

A. Place a tongue blade on the front of the tongue and ask the client to say
“ah”

B. Place a tongue blade lightly on the posterior aspect of the tongue.

C. Place a tongue blade on the middle of the tongue and ask the client to
cough.

D. Place a tongue blade on the uvula

24. A registered nurse is observing a nursing student auscultate the breath
sounds of a client. The registered nurse intervenes if the nursing student
performs which incorrect action?

A.Asks the client to sit straight up

B.Has the client breathe slowly and deeply through the mouth

C.Place the stethoscope directly on the client’s skin

D.Uses the bell of the stethoscope

25. Which of the following factors are major components of a client’s general
background drug history?

A.Allergies and socioeconomic status

B.Urine output and gastric reflex

C.Gastric reflex and age

D.Bowel habits and allergies

26. Before administering the evening dose of a prescribed medication, the nurse on the
evening shift finds an unlabeled filled syringe in the client’s medication drawer. What
should the nurse do?

A. Discard the syringe to avoid a medication error.

B. Obtain a label for the syringe from the pharmacy.

C. Use the syringe because it looks like it contains the same medication the nurse was
prepared to give.

D. Call the day nurse to verify the contents of the syringe.

 27. A nurse is preparing to administer a tuberculin test to a client via intradermal route.
Which of the following actions should the nurse perform when administering this test to
the client?

A. Inject the medication and place a pressure dressing over the medication site.

B. Massage the area with an alcohol swab after injection to ensure that the medication is
absorbed.

C. Administer the medication with the needle bevel facing downward at a 10- to 15-
degree angle.

D. Make a circular mark around the injection site after administration of the tuberculin
test.
 28. A nursing student is assigned to administer an iron injection to a client. The
coassigned nurse asks the student about the technique for administration of this
medication. The student indicates understanding of the administration procedure by
identifying the correct injection site and method as:

A. Anterolateral thigh using an air-lock

B. Gluteal muscle using Z-track technique

C. Subcutaneous tissue of the abdomen using a 1-inch needle

D. Deltoid muscle using a 1-inch needle

29. A nurse has administered an injection to a client. After the injection, the
nurse accidentally drops the syringe on the floor. Which nursing action is
appropriate in this situation?

A.Carefully pick up the syringe from the floor and gently recap the needle.

B.Carefully pick up the syringe from the floor and dispose of it in a sharps
container

C.Obtain a dust pan and mop to sweep up the syringe

D.Call the housekeeping department to pick up the syringe

30. A nurse plans to administer a medication by intravenous (IV) bolus
through the primary IV line. The nurse notes that the medication is
incompatible with the primary IV solution. Which of the following is the
appropriate nursing action to safely administer the medication?

A.Call the physician for an order to change the route of the medication.

B.Start a new IV line for the medication.

C.Flush the tubing before and after the medication with normal saline

D.Flush the tubing before and after the medication with sterile water
 31. The nurse is preparing a medication for the client and observes
the date of expiration occurred two months ago. Which action should
the nurse perform?

A.Give the medication.

B.Discard the medication.

C.Omit the medication.

D.Return the medication to the pharmacy.

 32. The nurse prepares to administer medication by the
buccal route. Where should the nurse place this medication?

A. On the client’s skin

B. Between the client’s cheek and gum

C. Under the client’s tongue

D. In the client’s conjunctival sac

 33. A client is to receive several oral medications at the same administration
time. Which nursing instruction or action is appropriate in this situation?

A.Tell the client to take all the medications at once.

B.Advise the client to take each medication with 8 oz of water.

C.Leave the medications at the bedside for the client to take when desired.

D.State the name and action or use of each medication before administering it.
34. The nurse is assessing a client for the risk of falls. The
nurse should collect:

A. Gait and balance information

B. The agency’s restraint policy

C. The family’s psychosocial history

D. The client’s dietary preferences

 35. The first priority when caring for a client at risk for falls is:

A.Placing the call light for easy access.

B.Keeping the bed in the lowest possible position

C.Instructing the client not to get out of bed without assistance

D.Keeping the bed pan available so that the client doesn’t have to get
out of bed.
 36. A client is diagnosed with a nosocomial infection caused by methicillin-
resistant Staphylococcus aureus and contact precautions are initiated. The
nurse prepares to provide colostomy care to the client and obtains which of the
following protective items needed to perform this procedure?

A.Gloves and gown

B.Gloves and goggles

C.Gloves, gown and shoe protectors

D.Gloves, gown, goggles and face shield

37. Two nurses are leaving a client’s room whose care required them to wear
a gown, mask and gloves. Which of the following actions by these nurses
could lead to the spread of infection?

A. Removing the gown without rolling it from inside out.

B. Taking off the gloves first before removing the gown.

C. Washing the hands after the entire procedure has been completed.

D. Removing the gloves and then removing the gown using the neck ties.
 38. Policy and procedure dictate that hand washing is a requirement when
caring for clients. Which statement about hand washing is true?

A.Frequent hand washing reduces transmission of pathogens from one client

to another.

B.Wearing gloves is a substitute for hand washing

C.Bar soap, which is generally available, should be used for hand washing

D.Waterless products shouldn’t be used in situations in which running water is

unavailable
39. The nurse formulates a diagnosis of Impaired gas exchange. Which
outcome is most appropriate based upon this nursing diagnosis?

A.The client maintains a reduced cough effort to lessen fatigue.

B.The client restricts fluid intake to prevent overhydration

C.The client reduces daily activities to a minimum

D.The client has normal breath sounds in all lung fields

  
40. A client has a nursing diagnosis of Ineffective airway clearance related to
poor coughing. When planning this client’s care, the nurse should include
which intervention?

A.Increasing fluids to 2,500 ml / day

B.Teaching the client how to deep-breathe and cough

C.Improving airway clearance

D.Suctioning the client every 2 hours

  
41. The client exhibits restlessness and dyspnea. To evaluate a client
for hypoxia, the physician is most likely to order which laboratory
test?

A. Red blood cell count

B. Sputum culture

C. Total hemoglobin

D. ABG analysis
42. The physician orders supplemental oxygen for a client with
respiratory problem. To provide the highest possible oxygen
concentration, the nurse expects to use which oxygen delivery
device?

A.Nasal cannula

B.Venturi mask

C.Partial rebreathing mask

D.Nonrebreathing mask
43. Which intervention should the nurse use when administering
oxygen by face mask to a client?

A.Secure the elastic band tightly around the client’s head.

B.Assist the client to the semi-Fowler’s position if possible

C.Apply the face mask from the client’s chin up over the nose.

D.Loosen the connectors between the oxygen equipment and

humidifier.
 44. The nurse is instructing the client with respiratory problem on how to
perform breathing technique that will assist in exhaling carbon dioxide and
open the airways. The nurse teaches the client which technique?

A. Pursed-lip breathing

B. Intercostals chest expansion

C. Abdominal breathing

D. Chest physical therapy

 45. A client hospitalized with pneumonia has thick, tenacious
secretions. To help liquefy these secretions, the nurse should:

A.Turn the client every 2 hours

B.Elevate the head of the bed 30 degrees

C.Encourage increased fluid intake

D.Maintain a cool room temperature

46. What method would the nurse use to most accurately
assess the effective of a weight loss diet for the client?

A.Checking daily weights

B.Checking serum protein levels

C.Doing daily calorie counts

D.Monitoring daily intake and output

47. The client has not eaten or had anything to drink for 4 hours following two
episodes of nausea and vomiting. Which of the following items would be the
best to offer him who is ready to try resuming oral intake?

A.Ginger ale

B.Gelatin

C.Toast

D.Dry cereal
48. The client is admitted to the health care facility after 3 days of nausea,
vomiting and fever. Which nursing diagnosis takes highest priority for this
client?

A.Excessive fluid volume related to intracellular fluid shift

B.Imbalanced nutrition: less than body requirements related to decreased

intake

C.Deficient fluid volume related to nausea and vomiting

D.Ineffective tissue perfusion related to hyperventilation

 49. When formulating the plan of care for a client receiving a
nasogastric tube feeding., the nurse keeps in mind that:

A.Aspiration is a concern with an NGT feeding.

B.The client needs to be maintained in a supine position.

C.The NGT needs to be changed with every other feeding.

D.The rate of the feeding needs to be increased if the infusion rate

falls behind schedule.
 50. A client complains of abdominal discomfort and nausea while
receiving tube feedings. Which intervention is most appropriate for this
problem?

A.Give the feedings at room temperature

B.Stop the feedings and check for residual volume

C.Place the client in semi-Fowler’s position while feeding

D.Change the feeding container daily

 51. NGT irrigations are prescribed to be performed once every shift. The
client’s serum electrolyte results indicate a potassium level of 4.5 mEq/L and
a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse
selects which solution to use for the NGT irrigation?

A.Tap water

B.Sterile water

C.Sodium chloride

D.Distilled water
52. An older client complains of chronic constipation. The nurse tells
the client to:

A.Include rice and bananas in the diet.

B.Increase the intake of sugar-free products

C.Increase fluid intake to at least 8 glasses a day and increase

dietary fiber

D.Increase potassium in the diet.

 53. A nurse is administering a cleansing enema to a client with a fecal
impaction. Before administering the enema, the nurse places the client in
which position?

A.Left Sims’ position

B.Right Sims’ position

C.On the left side of the body, with the head of the bed elevated 45 degrees

D.On the right side of the body, with the head of the bed elevated 45 degees
 54. A client who’s dehydrated has urinary incontinence and
excoriation in the perineal area. Which action would be a priority?

A.Keeping the perineal area clean and dry

B.Offering the urinal every 3 hours

C.Maintaining a fluid intake of 1 L/day

D.Applying moist, warm compresses to the client’s groin

  
55. When placing an indwelling urinary catheter in a female client,
the nurse should advance the catheter how far into the urethra?

A.2” (5cm)

B.6” (15cm)

C.8” (20cm)

D.½” (1cm)
56. A nurse is giving a bed bath to the client. In order to increase venous
return the extremities, the nurse bathes the client’s extremities by using:

A.Long, firm strokes from distal proximal areas

B.Firm circular strokes from proximal to distal areas

C.Short, patting strokes from distal to proximal areas

D.Smooth, light strokes back and forth from proximal to distal areas
57. When providing oral hygiene for an unconscious client, the
nurse must take which essential action?

A.Swabbing the client’s lips, teeth and gums with lemon glycerin

B.Cleaning the client’s tongue with gloved fingers

C.Placing the client in semi-Fowler’s position

D.Placing the client in a side-lying position

  
58. A nurse is providing mouth care to the unconscious client. The
nurse avoids which of the following actions during this procedure?

A.Turning the head to one side.

B.Using a bite stick or padded tongue blade.

C.Using oral suction equipment.

D.Rinsing with a large volume of fluid.

59. Which statement, if made by the client, indicates that teaching
about improving sleep is necessary?

A.“I swim three times a week.”

B.“I have stopped smoking cigars.”

C.“I drink hot chocolate before bedtime.”

D.“I read for 40 minutes before bedtime.”

60. A nursing diagnosis of disturbed sleep pattern is formulated. The
nurse encourages the client to do which of the following to best
enhance nighttime sleep?

A.Eat a large bedtime snack.

B.Drink a glass of milk.

C.Eat a snack with spicy ingredients.

D.Avoid caffeine products 1 hour before sleep.

  
61. A client is diagnosed with deep vein thrombophlebitis. A nurse develops
a plan of care for the client and includes which client position or activity in
the plan?

A.Out-of-bed activities as desired

B.Bed rest with the affected extremity kept flat

C.Bed rest with elevation of the affected extremity

D.Bed rest with the affected extremity in a dependent position

 62. A nurse is caring for an older client who is on bed rest. The
nurse plans which intervention to prevent respiratory complications?

A.Decreasing oral fluid intake

B.Monitoring vital signs every shift

C.Changing the client’s position every 2 hours

D.Instructing the client to bear down every hour and hold the breath
63. The nurse is transferring a client from the bed to a chair. Which
action does the nurse take during this client transfer?

A.Positions the head of the bed flat

B.Helps the client dangle his legs

C.Stands behind the client

D.Places the chair facing away from the bed

 64. The nurse is preparing to help a client with weakness in his right
leg get out of bed to a wheelchair. Where should the nurse place the
wheelchair?

A.Parallel to the bed on the right side

B.Perpendicular to the bed on the right side

C.Parallel to the bed on the left side

D.Parallel to the bed on either side

65. When moving a client in bed, the nurse can ensure
proper body mechanics by:

A.Standing with her feet apart

B.Lifting the client to the proper position

C.Straightening her knees and back

D.Standing several feet from the client

66. A bed ridden immobile client is at risk of developing foot drop. The nurse
uses which of the following as the most effective preventive measure?

A.Heel protectors

B.Posterior splints

C.Pneumatic boots

D.Foot board
 67. The nurse who volunteers at a senior citizens’ center is planning
activities for the members who attend the center. Which activity would best
promote health and maintenance for these senior citizens?

A.Gardening every day for an hour

B.Sculpting once a week for 40 minutes

C.Cycling three times a week for 20 minutes

D.Walking 3 to 5 times a week for 30 minutes

68. A client has just had a blood infusion started. The nurse suspects a
possible hemolytic reaction to the blood. After stopping the blood
transfusion, which nursing intervention would not be carried out?
A.Return the blood bag to the laboratory.

B.Obtain frequent urine specimens.

C.Send a blood specimen to the laboratory for detection of intravascular

hemolysis.

D.Start another unit of blood to prevent further hemolysis.

69. The doctor orders 2 units of blood for a client who is bleeding.
Before blood administration, the nurse’s highest priority should be:
A.Obtaining the client’s vital signs

B.Letting the blood reach room temperature

C.Monitoring the hemoglobin and hematocrit levels

D.Determining the proper typing and cross matching of blood

70. Which nursing intervention is of primary importance
in the administration of blood?

A.Checking the flow rate C. Monitoring the vital signs

B.Identifying the client D. Maintaining BP
 71. A nurse hears an attending MD asking an intern to
prescribe a hypotonic IV solution for a client. Which of the
following IV solutions would the nurse expect to intern to
prescribe?
A.0.45% saline C. 10% dextrose in water
B.5% dextrose in water D. 5% dextrose in 0.9% saline
  
72. A nurse evaluates the patency of peripheral IV site and suspects an
infiltration. Which does the nurse implement to determine if the IV has
infiltrated?

A.Increases the infusion rate and observes for swelling

B.Checks the regional tissue for redness and warmth

C.Strips the tubing and assesses for a blood return

D.Gently palpates regional tissue for edema and coolness

 73. A client recovering from a knee replacement has normal saline solution ordered to
run at 125 ml/hour I.V. The I.V. bag was hung at 8:00 a.m. It’s now 3:00 p.m., and 300
ml have been infused. A nurse has just come on her shift at 3:00 p.m. Which of the
following actions is correct?

A. Discontinue the I.V. infusion when the bag is complete.

B. Instruct the client to increase his fluid intake.

C. Speed up the rate of the I.V. fluids.

D. Notify the doctor of the client’s status.

74. Nursing has a code of ethics that professional registered nurses follow
and:

A.Defines the principles by which nurses’ provide care to their clients.

B.Ensures identical care to all clients.

C.Protects the client from harm.

D.Improves self-health care.

75. The founder of modern nursing is:

A.Dorthea Dix.

B.Florence Nightingale.

C.Clara Barton.

D.Linda Richards
 76. Evidence-based practice is defined as :

A.The integration of best research evidence with clinical expertise and

patient values.

B.Scholarly inquiry of nursing and biomedical research literature.

C.Nursing care based on tradition.

D.Quality nursing care provided in an efficient and economically sound

manner.
77. Contemporary nursing requires that the nurse possess knowledge and
skills for a variety of professional roles and responsibilities. Examples
include:

A.Autonomy and accountability.

B.Following physician orders.

C.Providing bedside care.

D.Increased emphasis on health promotion and illness prevention.

78. Advanced practice nurses generally:

A.Work in the university setting.

B.Function independently.

C.Work in acute care settings.

D.Function as unit directors.

 79. Descriptive theories:

A.Provide a structural framework for broad abstract ideas.

B.Describe phenomena.

C.Reflect practice and address specific phenomena.

D.Have the ability to explain, relate, and in some situations predict nursing
phenomena.
80. A theory is a set of concepts, definitions, relationships, and
assumptions that:

A.Explain a phenomenon.

B.Formulate legislation.

C.Measure nursing functions.

D.Reflect the domain of nursing practice.

  
81. There is a contemporary move toward nursing science---or evidenced-based practice.
This suggests:

A. Scientists will decide nursing decisions.

B. Theories are tested and used to describe or predict client outcomes of nursing care.

C. Nursing will base client care on the practice of medicine, psychology, social work, and
other sciences.

D. One theory will guide nursing practice.

82. Maslow’s hierarchy of needs is useful to nurses who continually prioritize
a client’s nursing care needs. The most basic or first-level needs include:

A.Esteem and self esteem needs.

B.Self-actualization.

C.Love and belonging.

D.Air, water, food.

83. Leininger’s theory of cultural care diversity and universality specifically
addresses:

A.Caring for clients from unique cultures.

B.Caring for client’s who cannot adapt to internal and external

environmental demands.

C.Understanding of the humanistic aspects of life.

D.Variables affecting a client’s response to a stressor.

 84. As an art, nursing relies on knowledge gained from practice and
reflection of past experiences. As a science, nursing draws on:

A. A. Scientifically tested knowledge that is applied in the practice setting.

B. Physician generated research.

C. Experimental research.

D. Nonexperimental research.
85. What is the rationale for using a footboard in a post-stroke
client?

A.To promote plantar flexion of the feet

B.To promote dorsiflexion of the feet

C.To prevent external rotation of the hip

D.To prevent internal rotation of the hip

86. Before transferring a client from the bed to a wheelchair, the
initial action of the nurse is to:

A.Identify the client

B.Secure the wheelchair lock

C.Position the wheelchair parallel to the bed

D.Check the client’s room number

  
87. When determining the priority needs of a client, which of the following
should the nurse consider as the highest priority?

A.Providing a safe environment

B.Preservation of life

C.Ensuring growth and development

D.Minimizing environmental stimulation

88. Which of the following actions is not appropriate when using the Z-track
method of drug injection?

A.Use a needle that is at least 1” long.

B.Allow the needle to remain in the muscles for 10 sec when injecting the
medication.

C.Stretch the skin laterally.

D.Massage the injection site after to promote absorption of the drug.

89. Which of the following is the greatest value of written nursing care
plans in nursing practice?

A.Promote individualized care.

B.Ensure proper documentation

C.Facilitate review of information.

D.Enhance communication of staff members.

 90. Which of the following is considered as one of the most
important responsibilities of the nurse when a client undergoes
diagnostic testing?

A.Report the result to the physician.

B.Inform the client of the result.

C.Analyse the result.

D.Obtain the results directly from the laboratory.

 91. Which of the following statements about handwashing is not
true?

A.Alcohol based or waterless products can be used to substitute for

water.

B.When the nurse is wearing gloves during client contact,

handwashing is not required.

C.Hand washing is the most basic way of preventing the spread of

infection.
 92. Which of the following practices will not prevent the spread of
infection?

A.Hand washing in between the client contact.

B.Discarding used needles uncapped in an impenetrable container.

C.Use of gloves when administering IM injections.

D.Covering the bedpan before discarding the feces out of the client’s
room.
93. Which of the following is the best way to prevent the spread of
infection?

A.Use a private room.

B.Having a complete immunization.

C.Wearing gloves.

D.Hand washing in between client contact.

94. Which of the following questions is not appropriate to ask a
client during pain assessment?

A.“Describe what it feels like.”

B.“Are you in pain?”

C.“Tell me about your pain.”

D.“What other feelings and discomforts do you experience with

pain?”
95. The Wong-Baker FACES rating scale is a visual pain scale that
is used to assess pain in children. This scale identifies the:

A.Intensity and severity of pain

B.Location of pain

C.Radiation of pain

D.Time when the pain occurs

 96. When obtaining a sterile urine specimen from a client’s
indwelling urinary catheter, the nurse should use which equipment:

A.Suction

B.Sterile syringe and needle

C.Clean container

D.Sterile bottle
97. Which of the following statements best describes charting by exception?

A.A chronological account of the client’s status and treatment written in

paragraphs.

B.A narrative recording on separate sheets by each member of the health

team.

C.Detailed flow charts and emphasis on the changes in the client’s condition.

D.Documentation that is limited only to significant findings.

 98. The nurse utilizes the focus charting. The three main
components of this method are summarized by the letters
DAR which stands for?
1)Data
2)Activity
3)Response
4)Action
5)Revision
A.1, 2 and 3 B. 2, 3 and 4 C. 1, 3 and 4 D. 1, 2
and 5
99. Problem oriented medical records focus on the client’s problem.
The four components are: database, problem list, plan of care and
progress notes. The progress notes sometimes takes the SOAPIER
format. The “R” in this format refers to:

A.Rationale

B.Revision

C.Reports

D.Review
100. Which of the following statements about charting is not true?

A.If an error is made on the chart, the nurse should draw a line and
initial it.

B.The original copy of the chart is owned by the hospital;

C.When using the SOAPIER method, R stands for research.

D.The purpose for auditing the nurses’ notes is to assess the

quality of client care.