1.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. The nurse notes that a clients intravenous (IV) site is cool, pale, and swollen, and the
solution is not infusing. The nurse concludes that which of the following complications has
occurred?
A. Infection B. Phlebitis C. Infiltration
D. Thrombosis
Correct Answer: C
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue.
Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous
tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV
solution will stop. The corrective action is to remove the catheter and start a new IV line at
another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the
site, not coolness.
2. When two nursing diagnoses appear closely related, what should the nurse do first to
determine which diagnosis most accurately refl ects the needs of the patient?
A. Reassess the patient
C. Analyze the secondary to factors
B. Examine the related to factors
D. Review the defi ning characteristics
RAtionale
A. 1. If a thorough assessment is completed initially, a reassessment should not be necessary.
B. To establish which of two nursing diagnoses is most appropriate is not dependent upon
identifying the factors that contributed to (also known as related to or etiology of ) the nursing
diagnosis. These factors are identifi ed after the problem statement is identifi ed.
C. To establish which of two nursing diagnoses is more appropriate is not dependent upon
analyzing the secondary to factors. Secondary to factors generally are medical conditions that
precipitate the related to factors. The secondary to factors are identifi ed after the related to
factors of the problem are identifi ed.
D. The first thing the nurse should do to differentiate between two closely associated
nursing diagnoses is to
compare the data collected to the major and minor defi ning characteristics of each of
the nursing diagnoses being considered.
3. The nurse performs an assessment of a newly admitted patient. The nurse understands that
this admission assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls
B. Ensure that the patients skin is intact
C. Establish a therapeutic relationship
D. Identify important data
RATIONALE
A. Although completing a nursing admission assessment includes an assessment of the risk for
falls, it is only one component of the assessment.
B. Although completing a nursing admission assessment includes an assessment of the skin, it is
only one component of the assessment.
C. Although completing a nursing admission assessment helps to initiate the nursepatient
relationship, it is not the primary purpose of completing a nursing admission assessment.
D. This is the primary purpose of a nursing admission assessment. Data must be
collected and then analyzed to determine significance, and grouped in meaningful
clusters before a nursing diagnosis can be made.
4. The nurse identifies that the patient statement that provides subjective data is:
A. Im not sure that I am going to be able to manage at home by myself.
B. I can call a home-care agency if I feel I need help at home.
C. What should I do if I have uncontrollable pain at home?
D. Will a home health aide help me with my care at home?
A. This is subjective information because it is the patients perception and can be
verifi ed only by the patient. Subjective data are those adaptations, feelings, beliefs,
preferences, and information that only the patient can confirm.
B. This is neither subjective nor objective. It is a statement indicating an understanding of how to
seek home care services after discharge.
C. This is neither subjective nor objective. It is a question indicating that the patient wants more
information about how to control pain when at home.
D. This is neither subjective nor objective. It is a statement exploring who will provide assistance
with care once the patient goes home.
5. The nurse understands that evaluation most directly relates to which aspect of the Nursing
Process?
A. Goal
B. Problem
C. Etiology
D. Implementation

A. To evaluate the effectiveness of a nursing action, the nurse needs to compare the
actual patient outcome with the expected patient outcome. The expected outcomes
are the measurable data that refl ect goal achievement, and the actual outcomes are
what really happened.
B. The problem is associated with the first half (problem statement) of the Nursing Diagnosis, not
the Evaluation, step of the Nursing Process.
C. Etiology is a term used to identify the factors that relate to or contribute to the problem
statement of the Nursing Diagnosis, not the Evaluation, step of the Nursing Process.
D. Implementation is a step separate from Evaluation in the Nursing Process. Nursing care must
be implemented before it can be evaluated.
6. The nurse comes to the conclusion that a patients elevated temperature, pulse, and
respirations are significant. What step of the Nursing Process is being used when the nurse
comes to this conclusion?
A. Implementation 2. Assessment
3. Evaluation
4. Diagnosis
A. This is not an example of the Implementation step of the Nursing Process. During the
Implementation step, planned nursing care is delivered.
B. This is not an example of the Assessment step of the Nursing Process. Although data may be
gathered during the Assessment step, the manipulation of the data is conducted in a different
step of the Nursing Process.
C. This is not an example of the Evaluation step of the Nursing Process. Evaluation occurs when
actual outcomes are compared with expected outcomes, which refl ect attainment or
nonattainment of the goal.
D. During the Diagnosis step of the Nursing Process, data are critically analyzed and
interpreted; signifi cance of data is determined; inferences are made and validated;
cues and clusters of cues are compared with the defi ning characteristics of nursing
diagnoses; contributing factors are identifi ed; and nursing diagnoses are identifi ed
and organized in order of priority.
7. When the nurse considers the Nursing Process, the word identify is to recognize as the
word do is to:
A. Plan
B. Evaluate C. Diagnose D. Implement
1. The words identify and recognize have the same definition. They both mean the same as that
which is known. The word plan does not fi t the analogy because the definitions of plan and do
are different. The word plan means a method of proceeding. The word do means to carry into
effect or to accomplish.
2. The words identify and recognize have the same definition. They both mean the same as that
which is known. The word evaluate does not fit the analogy because the definitions of evaluate
and do are different. The word evaluate means to determine the worth of something, whereas
the word do means to carry into effect or to
accomplish.
3. The words identify and recognize have the same definition. They both mean the same as that
which is known. The word diagnose does not fit the analogy because the definitions of diagnose
and do are different. The word diagnose means to identify the patients human response to an
actual or potential health problem. The word do means to carry into effect or to accomplish.
4. This is the correct analogy. The words identify and recognize have the same defi
nition. They both mean the same as that which is known. The words do and implement
both have the same defi nition. They both mean to carry out some action.
8. The nurse is collecting subjective data associated with a patients anxiety. Which assessment
method should be used to collect this information?
A. Observing
B. Inspecting
C. Auscultation
D. Interviewing
1. Observation is the deliberate use of all the senses, and involves more than just inspection and
examination. It includes surveying, looking, scanning, scrutinizing, and appraising. Although the
nurse makes inferences based on data collected by observation, this is not as effective as
another data collection method to identify subjective data associated with a patients anxiety.
2. Inspection involves the act of making observations of physical features and behavior. Although
the nurse observes behaviors and makes inferences based on their perceived meaning, another
data collection method is
more effective in identifying subjective data associated with a patients anxiety.
3. Auscultation is listening for sounds within the body. This collects objective, not subjective,
data, which are measurable.
4. Interviewing a patient is the most effective data collection method when collecting
subjective data associated with a patients anxiety. The patient is the primary source
for subjective data about beliefs, values, feelings, perceptions, fears and concerns.
9. Which nursing action reflects an activity associated with the diagnosis step of the Nursing
Process?
A. Formulating a plan of care
B. Identifying the patients potential risks
C. Designing ways to minimize a patients stressors

D. Making decisions about the effectiveness of patient care

8. This occurs during the Planning, not Diagnosis, step of the Nursing Process.
2. Potential risk factors are identified during the Diagnosis step of the Nursing
Process. Risk diagnoses are designed to address situations where patients have a
particular vulnerability to health problems.
3. This occurs during the Planning, not Diagnosis, step of the Nursing Process.
4. This occurs during the Evaluation, not Diagnosis, step of the Nursing Process.
10. The nurse collects objective data when a hospitalized patient states:
A. I am hungry.
C. I ate half my lunch.
B. I feel very warm.
D. I have the urge to urinate.
1. Hunger is an example of subjective, not objective, data. Subjective data are those adaptations,
feelings, beliefs, preferences, and information that only the patient can confi rm.
2. Feeling warm is an example of subjective, not objective, data. Subjective data are those
adaptations, feelings, beliefs, preferences, and information that only the patient can confi rm.
3. The amount of food eaten by a patient can be objectively verifi ed. The nurse
measures and documents the percentage of a meal ingested by a patient to quantify
the amount of food consumed.
4. Having the urge to void is an example of subjective, not objective, data. Subjective data are
those adaptations, feelings, beliefs, preferences, and information that only the patient can
confirm.
11. During which of the fi ve steps in the Nursing Process does the nurse determine whether
outcomes of care are achieved?
A. Implementation B. Evaluation
3. Diagnosis
4. Planning
11. 1. During the Implementation step of the Nursing Process, outcomes are not determined, but
rather planned nursing care is delivered.
2. Evaluation occurs when actual outcomes are compared with expected outcomes
that reflect goal achievement. If the goal is achieved, the patients needs are met.
3. During the Diagnosis step of the Nursing Process, outcomes are not determined; rather, the
nurse diagnoses human responses to actual or potential health problems.
4. During the Planning step of the Nursing Process, expected outcomes are determined, but their
achievement is measured in another step of the Nursing Process.
12. When considering the Nursing Process, the nurse understands that the word observe is to
assess as the word determine is to:
A. Plan
B. Analyze C. Diagnose D. Implement
1. The defi nitions of the words observe and assess are similar. Observe means to examine
something scientifically, and assess means to determine the significance of something. The word
plan does not fi t the analogy because the
definitions of the words plan and determine are not similar. Determine means to reach a
decision. Plan means to carry into effect or to accomplish.
2. The defi nitions of the words observe and assess are similar. Observe means to examine
something scientifi cally, and assess means to determine the signifi cance of something. The
word analyze does not fi t the analogy because analyze is not a step in the Nursing Process. The
steps in the Nursing Process are Assessment, Diagnosis, Planning, Implementation, and
Evaluation.
3. The defi nitions of the words observe and assess are similar. Observe means to
examine something scientifi cally, and assess means to determine the significance of
something. The word diagnose appropriately completes the analogy because the defi
nitions of determine and diagnose are similar. Determine means to reach a decision
about something and diagnose means to make a decision based on the assessment
and analysis of a human response
4. The defi nitions of the words observe and assess are similar. Observe means to examine
something scientifi cally, and assess means to determine the signifi cance of something. The
word implement does not fit the analogy because the
definitions of determine and implement are not similar. Determine means to reach a decision
about something and
implement means to carry out some action.
13. An essential concept related to understanding the Nursing Process is that it:
A. Is dynamic rather than static
C. Moves from the simple to the complex
B. Focuses on the role of the nurse
D. Is based on the patients medical problem
1. The Nursing Process is a dynamic five-step problem-solving process (Assessment,
Diagnosis, Planning,
Implementation, and Evaluation) designed to diagnose and treat human responses to
health problems. The nurse moves among the steps in response to the changing
needs of the patient.
2. The Nursing Process focuses on the needs of the patient, not the role of the nurse.
3. Moving from the simple to the complex is a principle of teaching, not the Nursing Process. The
Nursing Process is a complex interactive five-step problem-solving process designed to meet a

patients needs. It requires an understanding of systems and information processing theory, and
the critical-thinking, problem-solving, decision-making, and diagnostic-reasoning processes.
4. The Nursing Process is concerned with a persons human responses to actual or potential
health problems, not the patients medical problem.
14. The nurse is caring for a male patient with a urinary elimination problem. Which is the most
accurately stated goal? The patient will:
1. Be taught how to use a urinal when on bed rest.
2. Experience fewer incontinence episodes at night.
3. Be assisted to the toilet every two hours and whenever necessary.
4. Transfer independently and safely to a commode before discharge.
RATIONALE
1. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a
goal.
2. This goal is inappropriate because the word fewer is not specific, measurable, or objective.
3. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a
goal.
4. This is a correctly worded goal. Goals must be patient-centered, measurable,
realistic, and include the time frame
in which the expected goal is to be achieved. The word independently indicates that
no help is needed, and the word safely indicates that no injury will occur. The time
frame is before discharge.
15. Which word best describes the role of the nurse when using the Nursing Process to meet the
needs of the patient holistically?
A. Teacher B. Advocate C. Surrogate D. Counselor
1. Although functioning as a teacher is an important role of the nurse, it is a limited role
compared to another option. As a teacher, the nurse helps the patient gain new knowledge about
health and health care to maintain or restore health.
2. When the nurse supports, protects, and defends a patient from a holistic
perspective, the nurse functions as an
advocate. Advocacy includes exploring, informing, mediating, and affirming in all
areas to help a patient navigate the
health-care system, maintain autonomy, and achieve the best possible health
outcomes.
3. The word surrogate is not the word that best describes this scenario. The nurse is placed in the
surrogate role when a patient projects onto the nurse the image of another and then responds to
the nurse with the feelings for the other persons image.
4. Although functioning as a counselor is an important role of the nurse, it is a limited role
compared to another option. As counselor, the nurse helps the patient improve interpersonal
relationships, recognize and deal with stressful psychosocial problems, and promote
achievement of self-actualization.
16. The nurse understands that the word most closely associated with scientifi c principles is:
A. Data
B. Problem C. Rationale D. Evaluation
1. The word data (evidence or information) is not associated with the term scientific principles
(established rules of action).
2. The word problem (diffi culty or crisis) is not associated with the term scientific principles
(established rules of action).
3. The word rationale (justifi cation based on reasoning) is closely associated with the
term scientific principles (established rules of action). Scientifi c principles are based
on rationales.
4. The word evaluation (determining the value or worth of something) is not associated with the
term scientific principles (established rules of action).
17. The nurse teaches a patient to use visualization to cope with chronic pain. This action reflects
which step of the Nursing Process?
A. Planning B. Diagnosis C. Evaluation
D. Implementation
1. This is not an example of the Planning step of the Nursing Process. During the Planning step,
the nurse identifi es and plans the nursing interventions that seem most likely to be effective.
2. This is not an example of the Diagnosis step of the Nursing Process. During the Diagnosis step
of the Nursing Process,
data are critically analyzed and interpreted; significance of data are determined; inferences are
made and validated; signs and symptoms and clusters of signs and symptoms are compared with
the defi ning characteristics
of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and
organized in order of priority.
3. This is not an example of the Evaluation step of the Nursing Process. Evaluation occurs when
actual outcomes are compared with expected outcomes that reflect goal achievement.
4. This is an example of the Implementation step of the Nursing Process. During the
Implementation step, planned nursing care is delivered.

18. The nurse understands that the primary goal of the assessment phase of the Nursing Process
is to:
A. Build trust and rapport
D. Identify and validate the medical
B. Collect and cluster data
diagnosis
C. Establish goals and outcomes
1. Although trust and rapport may be established during the assessment phase of the Nursing
Process, they are not the primary purpose. The development of trust and rapport generally takes
time.
2. The primary purpose of the Assessment step of the Nursing Process is to collect
data from various sources using
a variety of approaches. After data are collected, they are clustered into meaningful
categories and interpreted
during the Diagnosis step of the Nursing Process.
3. When a five-step Nursing Process is followed, identifying goals and outcomes occur during the
Planning, not Assessment, step of the Nursing Process.
4. Identifying and validating the medical diagnosis are not within a Registered Nurses legal
scope of nursing practice.
19. Which human response identified by the nurse is an example of objective data?
A. Pain of 5 on a 1 to 10 pain scale B. Irregular radial pulse of 50 bpm 4. Shortness of breath 5.
Dizziness
1. A patients perception about a pain level is an example of subjective, not objective, data.
Subjective data are those adaptations, feelings, beliefs, preferences and information that only
the patient can confi rm.
RATIONALE
2. A radial pulse is objective, not subjective, information. Objective data are
measurable and checkable.
3. A patients complaint about shortness of breath is an example of subjective, not objective,
data.
Subjective data are those adaptations, feelings, beliefs, preferences, and information that only
the patient can confirm.
4. A patients complaint about dizziness is an example of subjective, not objective, data.
Subjective data are those adaptations, feelings, beliefs, preferences, and information that only
the patient can confirm.
20. The Planning step of the Nursing Process is infl uenced most directly by the:
A. Related factors B. Diagnostic label C. Secondary factors
D. Medical diagnosis
1. Related factors (i.e., contrbuting to factors, etiology) contribute to the problem
statement of the Nursing Diagnosis and directly impact on the Planning step of the
Nursing Process. Nursing interventions are selected to minimize or relieve the effects
of the related factors. If nursing interventions are appropriate and effective, the
human response identified in the problem statement part of the Nursing Diagnosis
will be resolved.
2. The Planning step of the Nursing Process includes setting a goal, identifying the outcomes that
will refl ect goal achievement, and planning nursing interventions. Although the wording of the
goal is directly infl uenced by the diagnostic label (problem statement of the Nursing Diagnosis),
the selection of nursing interventions is not.
3. Secondary factors generally have only a minor influence on the Planning step of the Nursing
Process.
4. The medical diagnosis does not influence the Planning step of the Nursing Process. The nurse
is concerned with human responses to actual or potential health problems, not the medical
diagnosis
21. The nurse is obtaining a patients blood pressure. Which information is most important for
the nurse to document?
1. Staff member who took the blood pressure
2. Patients tolerance to having the blood pressure taken
3. Position of the patient if the patient is not in a sitting position
4. Difference between the palpated and auscultated systolic readings
RATIONALE
1. Although this should be done, it is not the most important information that should be
documented.
2. This is necessary only if the patient did not tolerate the procedure.
3. The patients position when the blood pressure is measured may influence results.
Generally, systolic and diastolic
readings are lower in the horizontal than in the sitting position. There is a lower
reading in the uppermost arm when a
person is in a lateral recumbent position. A change from the horizontal to an upright
position may result in a temporary decrease (5 to 10 mm Hg) in blood pressure; when

it exceeds 25 mm Hg systolic or 10 mm Hg diastolic, it is called orthostatic

hypotension.
4. This is unnecessary because they are approximately the same
22. The nurse is assessing a patients bilateral pulses for symmetry. However, the nurse should
not assess which pulse sites on both sides of the body at the same time?
1. Radial
2. Carotid
3. Femoral 4. Brachial
RATIONALE
1. There are no contraindications for palpating both radial arteries at the same time.
2. It is unsafe to palpate both carotid arteries at the same time. Slight compression of
both carotid arteries can interfere with blood flow to the brain. In addition,
compression of the carotid arteries can stimulate the carotid sinuses, which causes a
reflex drop in the heart rate.
3. There are no contraindications for palpating both femoral arteries at the same time.
4. There are no contraindications for palpating both brachial arteries at the same time.
23. The nurse is caring for a patient who is experiencing an increase in symptoms associated
with multiple sclerosis. Which term best describes a recurrence of symptoms associated with a
chronic disease?
1. Variance
2. Remission
3. Adaptation
4. Exacerbation
RATIONALE
1. Variance occurs when there is a variation or deviation from a critical pathway. This occurs
when goals are not met or interventions are not performed according to the stipulated time
period.
2. A remission is a period during a chronic illness of lessened severity or cessation of symptoms.
3. An adaptation is a physical or emotional response to an internal or external stimulus.
4. An exacerbation is the period during a chronic illness when symptoms reappear
after a remission or absence of symptoms
24. A patient with hypertension is given discharge instructions to take the blood pressure every
day. The nurse is evaluating a family member taking the patients blood pressure as part of the
patients discharge teaching plan. The nurse identifies that further teaching is necessary when
the family member:
1. Places the diaphragm of the stethoscope over the brachial artery
2. Applies the center of the bladder of the cuff directly over an artery
3. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat
4. Inserts the 2 earpieces of the stethoscope into the ears so that they tilt slightly forward
RATIONALE
1. This is a correct action when obtaining a blood pressure reading. The brachial artery is close to
the skins surface, and the diaphragm of the stethoscope is used for low-pitched sounds of a
blood pressure reading.
2. This ensures an accurate reading because it provides uniform and complete compression of
the brachial artery.
3. This may result in an inaccurate reading. The valve on the manometer should be
opened to allow the gauge to drop 2 to 3 mm Hg per heartbeat.
4. This ensures that the openings in the earpieces of the stethoscope are facing toward the ear
canal for uninterrupted transmission of sounds.
25. The nurse must assess for the presence of bowel sounds in a postoperative patient. The
nurse should auscultate the patients abdomen:
1. Prior to palpation
4. For at least three minutes in each
2. Using a warmed stethoscope
quadrant
3. Starting at the left lower quadrant
RATIONALE
1. Bowel sounds are auscultated before palpation and percussion because these
techniques stimulate the intestines and thus cause an increase in peristalsis and a
false increase in bowel sounds.
2. This is done for patient comfort, not to influence the accuracy of the assessment.
3. This is not necessary. Many people begin the systematic 4-quadrant assessment in the lower
right quadrant over the ileocecal valve where the digestive contents from the small intestine
empty through a valve into the large intestine.
4. This is unnecessary. Bowel sounds may be hyperactive (1 every 3 seconds) or hypoactive (1
every minute). After a sound is heard, the stethoscope is moved to the next site. For sounds to
be considered absent there must be
no sounds for 3 to 5 minutes.
26. The nurse is unable to palpate a patients brachial pulse. Which pulse should the nurse
assess to determine adequate brachial blood flow in this patient?
1. Radial
2. Carotid
3. Femoral 4. Popliteal
RATIONALE
1. The brachial artery splits (bifurcates) into the radial and ulnar arteries. When there
is an adequate radial pulse, the brachial artery must be patent.

2. This information is useless. The carotid arteries are in the neck while the brachial arteries are
in the arms. A carotid pulse site is located on the neck at the side of the larynx, between the
trachea and the sternomastoid muscle.
3. This information is useless. The femoral arteries are in the legs while the brachial arteries are
in the arms. A femoral pulse site is in the groin in the femoral triangle. It is in the anterior, medial
aspect of the thigh, just below the inguinal ligament, halfway between the anterior superior iliac
spine and the symphysis pubis.
4. This information is useless. The popliteal arteries are in the legs while the brachial arteries are
in the arms. A popliteal pulse site is in the lateral aspect of the hollow area at the back of the
knee (popliteal fossa).
27. The nurse is assessing a patients heart rate by palpating the carotid artery. What is the most
important thing the nurse should do when assessing a pulse at this site?
1. Monitor for a full minute
3. Press gently when palpating the site
2. Palpate just below the ear
4. Massage the site before assessing for rate
RATIONALE
1. This is unnecessarily long, and even slight compression can interfere with blood flow to the
brain.
2. This is not the site to access the carotid artery. A carotid pulse site is located on the neck at
the side of the larynx, between the trachea and the sternomastoid muscle.
3. The carotid artery should be palpated with a light touch to prevent an interference
in blood flow to the brain and stimulation of the carotid sinus that can cause a reflex
drop in the heart rate.
4. This is contraindicated. Massage can stimulate the carotid sinus located at the level of the
bifurcation of the carotid artery, which results in a reflex drop in the heart rate.
28. Which usually is unrelated to a nursing physical assessment?
1. Posture and gait
2. Balance and strength
3. Hygiene and grooming
4. Blood and urine
values
RATIONALE
Assessing posture and gait are within the scope of nursing practice because they reflect human
responses.
2. Assessing balance and strength are within the scope of nursing practice because they refl ect
human responses.
3. Assessing hygiene and grooming are within the scope of nursing practice because they reflect
human responses.
4. Ordering and assessing urine and blood values are not in the independent practice
of nursing. These assessments are dependent or interdependent functions of the
nurse and are covered by specific orders or standing orders respectively.
29. A patient consistently tries to pull out a urinary retention catheter. As a last resort to
maintain integrity of the catheter and patient safety, the nurse obtains an order for a restraint.
Which type of restraint is most appropriate in this situation?
A. Mummy restraint
B. Elbow restraint
C. Jacket restraint
D. Mitt restraint
RATIONALE
1. A mummy restraint usually is used to immobilize an infant or very young child during a
procedure.
2. An elbow restraint usually is used to prevent flexion of the elbow in an infant or young child to
prevent the pulling out of tubes.
3. A jacket restraint usually is used to keep a person from falling out of bed while not
immobilizing the extremities.
4. A mitt restraint covers the hand to prevent the fingers from grasping and pulling
out tubes.
30.The nurse must apply a hospital gown to a patient receiving an intravenous infusion in the
forearm. The nurse should:
1. Insert the IV bag and tubing through the sleeve from inside of the gown fi rst
2. Disconnect the IV at the insertion site, apply the gown, and then reconnect the IV
3. Close the clamp on the IV tubing no more than 15 seconds while putting on the gown
4. Don the gown on the arm without the IV, drape the gown over the other shoulder, and adjust
the closure behind the neck
RATIONALE
1. This ensures that the IV bag and tubing are safely passed through the armhole of
the gown before the patient puts the arm with the insertion site through the gown.
This prevents tension on the tubing and insertion site, which limits the possibility of
the catheter dislodging from the vein.
2. Disconnecting the IV tubing at the catheter insertion site is unsafe. This opens a closed system
unnecessarily, increasing the potential for infection.
3. This is unsafe. This stops the flow of the IV solution, which can result in blood coagulating at
the end of the catheter in the vein and compromising the patency of the IV tubing.

4. This leaves the patient exposed unnecessarily. It interferes with privacy, and the patient may
feel cold.
31. An appropriately worded goal associated with the nursing diagnosis Risk for Injury is, The
patient will be:
1. Taught how to call for help to ambulate.
3. Restrained when agitated.
2. Kept on bed rest when dizzy.
4. Free from trauma.
RATIONALE
1. This is a planned intervention, not a goal.
2. This is a planned intervention, not a goal.
3. This is a planned intervention, not a goal. In addition, it is inappropriate to restrain a person
automatically for agitation. A restraint should be used as a last resort to prevent the patient from
self-injury or injuring others.
4. This is an appropriate goal. It is realistic, specifi c, measurable, and has a time
frame. It is realistic to expect that all patients be safe. It is specifi c and measurable
because safety from trauma can be compared to standards of care within the
profession of nursing. It has a time frame because the words free from refl ect the
time frames of always, constantly, and continuously.
32. When teaching children about fi re safety procedures, the school nurse should teach them
that if their clothes catch on fire they should:
1. Yell for help
3. Take their clothes off
2. Roll on the ground
4. Pour water on their clothes
RATIONALE
1. This may eventually be done, but the child must do something immediately without waiting for
help to arrive.
2. Rolling on the ground will smother the flames and put the fi re out. Children should
be taught to: Stop, drop, and roll.
3. This may be impossible. In addition, it will take time and the clothing and skin will continue to
burn.
4. Finding and obtaining water will take too much time and the clothing and skin will continue to
burn. Something must be done immediately.
33. The nurse is assessing a patient who is being admitted to the hospital. Which is the most
important information collected by the nurse that indicates whether the patient is at risk for
physical injury?
1. Weakness experienced during a prior
3. Two recent falls that occurred at home
admission
4. The need for corrective eyeglasses
2. Medication that increases intestinal
motility
RATIONALE
1. Although this is important information, it is not the most important factor of the options
offered in this question. In addition, the prior admission may have been too long ago to have any
current relevance.
2. A patient with increased intestinal motility may experience diarrhea, which may place the
patient at risk for a fl uid and electrolyte imbalance, not a physical injury. Although a person with
diarrhea may need to use the toilet more frequently, a bedside commode or bedpan can be used
to reduce the risk of falls.
3. This is signifi cant information that must be considered because if falls occurred
before, they are likely to occur again. When a risk is identifi ed, additional injury
prevention precautions can be implemented.
4. Although this is important information, it is not the most important factor of the options
offered in this question.
34. The nurse is caring for a patient with a nasogastric tube for gastric decompression. Which
nursing action takes priority?
1. Positioning the patient in the semi3. Providing care to the nares at least every
Fowlers position
8 hours
2. Instilling the tube with 30 mL of air every
4. Discontinuing wall suction when providing
2 hours
care
RATIONALE
1. A nasogastric (NG) tube for gastric decompression passes down the esophagus,
through the cardiac sphincter, and into the stomach. The cardiac sphincter remains
slightly open because of the presence of the NG tube. The semi-Fowlers position
keeps gastric secretions in the stomach via gravity (preventing refl ux and aspiration)
and allows the gastric contents to be suctioned out by the NG tube.
2. This is not done routinely every 2 hours. This may be done to identify the presence of the tube
in the stomach and help re-establish patency of the tube when it is clogged.
3. This should be done more frequently to prevent irritation and pressure.
4. This is unnecessary and can result in vomiting and aspiration.
35. The nurse is preparing to draw up medication from a vial. What should the nurse do first?

1. Ensure that the needle is fi rmly attached to the syringe

2. Rub vigorously back and forth over the rubber cap with an alcohol swab
3. Inject air into the vial with the needle bevel below the surface of the medication
4. Draw up slightly more air than the volume of medication to be withdrawn from the vial
RATIONALE
1. This will ensure a tight seal and a closed system. If not firmly connected, the hub of
the needle may disengage from the barrel of the syringe during preparation or
administration of the medication when internal and external pressures are exerted on
the needle and syringe.
2. The top just needs to be swiped. Rubbing back and forth is a violation of surgical asepsis
because it reintroduces microorganisms to the area being cleaned.
3. This should be avoided because it causes bubbles that may interfere with the drawing up of an
accurate volume of solution.
4. Excess air in the closed system raises pressure in the vial, which may cause bubbles when
withdrawing the fl uid and result in an inaccurate volume of solution.
36. The instructions with a medication states to use the Z-track technique when administering
the injection. Therefore, the nurse should:
1. Pinch the site throughout the injection
2. Massage the site after the needle is removed
3. Remove the needle immediately after the medication is injected
4. Change the needle after the medication is drawn into the syringe
1. When the Z-track technique is used during an intramuscular injection, the skin and
subcutaneous tissue are pulled 1 to 1 inches to one side, not pinched.
2. Massage is contraindicated because it will force medication back up the needle track, which
may result in tissue irritation or staining.
3. Removal of the needle should be delayed 10 seconds to allow the medication to begin to be
dispersed and absorbed.
4. This ensures that medication is not on the outside of the needle, which prevents
tracking of the medication into subcutaneous tissue during needle insertion.
37. The nurse understands that a contraindication for the intake of medications via the oral route
is:
1. Diffi culty swallowing
2. Gastric suctioning
3. Unconsciousness
4. Nausea
18. 1. Nursing interventions, such as positioning, mixing a crushed medication in applesauce,
and dissolving a medication in a small amount of fluid, can be employed to facilitate the
ingestion of medication.
2. Gastric suctioning can be interrupted for 20 to 30 minutes after medication has been instilled
via a nasogastric tube.
3. Nothing that needs to be swallowed should ever be placed into the mouth of an
unconscious patient because of the risk for aspiration.
4. Vomiting, not nausea, is a contraindication for p.o. medications.
38. The nurse teaches the spouse of a patient how to insert a rectal suppository. The nurse
identifi es that further teaching is necessary when the spouse:
1. Lubricates the tip of the suppository
2. Wears a glove when inserting the suppository
3. Places the suppository two inches into the rectum
4. Inserts the suppository while the patient bears down
RATIONALE
1. Lubrication is required to limit tissue trauma and ease insertion.
2. Standard precautions should be employed when there is exposure to patients body fluids.
3. In an adult, a suppository should be inserted 4 inches to ensure it is beyond the
internal sphincter.
4. Bearing down increases intraabdominal pressure which impedes the insertion of the
suppository. The patient should be instructed to relax and breathe deeply and slowly while the
suppository is inserted.
39. The physician orders a medication that must be administered via the intramuscular route.
When administering this medication, the nurse knows that the site that has the highest risk for
injury is the:
1. Vastus lateralis 2. Rectus femoris 3. Ventrogluteal
4. Dorsogluteal
20. 1. The vastus lateralis site is not near large nerves or blood vessels and the muscle does not
lie over a joint. It is a preferred site for infants 7 months of age and younger.
2. The rectus femoris site is not near major nerves, blood vessels, or bones. It is a preferred site
for adults.
3. The ventrogluteal site is not near large nerves or blood vessels. It is a preferred site in adults
and children.
4. The dorsogluteal site has the highest risk for injury because of the close proximity
of the sciatic nerve, blood vessels, and bone.

40. The nurse adds a medication to an intravenous fl uid bag. Which nursing action is the
priority?
1. Attaching a completed IV additive label to the bag
2. Mixing the medication and solution by rotating the bag
3. Maintaining sterile technique throughout the procedure
4. Ensuring that the drug and the IV solution are compatible
RATIONALE
1. Although this is important for safe administration of a medication administered intravenously,
it is not the priority.
2. Although this should be done to ensure distribution of the medication throughout the IV
solution, it is not the priority.
3. Although this is important to prevent infection, it is not the priority.
4. An incompatibility can increase, decrease, or neutralize the effect of the
medication. Also, it may cause a compound or precipitate that can harm the patient.
This must be done before proceeding with subsequent steps of the procedure.
41. The nurse understands that the route of drug administration not considered parenteral is:
1. Epidural
2. Transdermal
3. Subcutaneous
4. Intramuscular
RATIONALE
1. A medication to be given via the epidural route is administered through a catheter inserted
into the epidural space.
2. Parenteral means outside the digestive system. However, in health care the
parenteral route refers to medications given by injection or infusion. Transdermal
medications are absorbed through the skin for a systemic effect.
3. A needle is required to reach the subcutaneous tissue, the layer of fat located below the
dermis and above muscle tissue.
4. A needle is required to reach the muscle layer beneath the dermis and subcutaneous tissue.
42. The nurse identifies that a patients pressure ulcer has just partial-thickness skin loss
involving the epidermis and dermis. The nurse documents that the patients pressure ulcer is:
1. Stage I
2. Stage II 3. Stage III 4. Stage IV
RATIONALE
1. In a Stage I pressure ulcer the skin is still intact and presents clinically as reactive hyperemia.
2. In a Stage II pressure ulcer the partial-thickness skin loss presents clinically as an
abrasion, blister, or shallow crater.
3. In a Stage III pressure ulcer there is fullthickness skin loss involving the subcutaneous tissue
that may extend to the underlying fascia. The ulcer presents clinically as a deep crater with or
without undermining.
4. In a Stage IV pressure ulcer there is fullthickness skin loss with extensive destruction, tissue
necrosis, or damage to muscle, bone or supporting structures.
43. Which is the most important nursing action when assisting a patient to move from a bed to a
wheelchair?
1. Applying pressure under the patients axillae areas when standing up
2. Lowering the bed to below the height of the patients wheelchair
3. Letting the patient help as much as possible when permitted
4. Keeping the patients feet within six inches of each other
RATIONALE
1. This should be avoided because it can injure nerves and blood vessels.
2. The bed should be higher, not lower, than the wheelchair so that gravity can facilitate the
transfer.
3. Encouraging the patient to be as selfsufficient as possible ensures that the transfer
is conducted at his/her pace,
promotes self-esteem, and decreases the physical effort expended by the nurse.
4. This will provide a narrow base of support and is unsafe.
44. A cane assists the client to walk with greater balance and support. Canes have the following
features for safety
and support:
1. feet (four, three, straight), adjustable to allow the elbow to bend slightly, a rubber cap.
2. feet (straight or two), adjustable to what the client feels is best.
3. four feet, a rubber tip at both ends.
4. three feet, enables speed, using two canes.
RATIONALE
(1) The cane can have four feet (quad), three feet (tripod), or be straight; the length should allow
the elbow to bend
slightly, and a rubber tip prevents slipping.

45. The standard walker is used when clients:

1. have poor balance, cannot stand up, have weak arms, and have good hand strength.
2. have poor balance, broken leg, or amputation.
3. have poor balance, cardiac problems, and cannot use crutches or cane.
4. have poor balance, autoimmune diseases, and weak arms.
(3) The use of the walker is used for clients who have balance, cardiac problems, or who cannot
use crutches or cane.
The client needs to be partial weight bearing and have strength in wrists and arms. The client
uses upper body to propel
the walker forward.
46. Which of the following clients are not a candidate for magnetic resonance imaging?
1. client with a pacemaker
2. client with a porcine heart valve
3. client with an arrythmia
4. client with an indwelling catheter
(1) Since a pacemaker is metal, a client with one could not undergo MRI, since the strong
magnet would interfere with
its function. A porcine heart valve is not metal, so it is acceptable. Clients with arrythmias may
need to be monitored,
but they can receive an MRI. An indwelling catheter is not a contraindication.
47. Which statement by a client indicates adequate understanding of care after a colposcopy?
1. I can use contraceptive foam tomorrow.
2. I will place a diaphragm in now.
3. I will place a pad to absorb the bleeding.
4. I can have intercourse with my spouse tonight.
(3) A small amount of bleeding is expected, and an absorbent pad can be used. The client is to
abstain from intercourse
and inserting objects into the vagina until healing of the biopsy site is confirmed.
48. Prior to an amniocentesis, what is important for the nurse to instruct the client to do?
1. Do not eat after midnight.
2. Do not drink after midnight.
3. Urinate just before the test.
4. Urinate just after the test.
(3) The client needs to be instructed to urinate just before the test, to minimize risk of
puncturing the bladder and aspirating
urine, instead of amniotic fluid. The client does not have to abstain from food or fluids.
49. Which of the following clients is most likely to receive an amniocentesis?
1. a hypertensive 28-year-old woman
2. a healthy 40-year-old woman
3. a depressed 32-year-old woman
4. a healthy 18-year-old woman
(2) An amniocentesis is indicated in women over age 35, with a family history of genetic
abnormalities or previous
miscarriages. Due to risks of the test, such as spontaneous abortion, premature labor, and
infection, the other options
due not warrant an amniocentesis.
50. Which of the following statements by a client indicates adequate understanding of a bone
marrow biopsy to
obtain a laboratory specimen?
1. The procedure will take less than five minutes.
2. I can go for a walk right after the procedure.
3. I will be given medication to minimize discomfort.
4. It is okay if the injection site becomes swollen.
(3) The client will be given a local anesthetic to minimize the discomfort of the needle
penetrating bone tissue. The
procedure generally takes 20 minutes. Bedrest needs to be maintained after the procedure for at
least 30 minutes. The
client needs to report swelling at the injection site, as it may be an indication of infection.
51. The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. The nurse notes that a clients intravenous (IV) site is cool, pale, and swollen, and the
solution is not infusing. The nurse concludes that which of the following complications has
occurred?
1. Infection 2. Phlebitis 3. Infiltration
4. Thrombosis
Correct Answer: 3
An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue.
Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous
tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV

solution will stop. The corrective action is to remove the catheter and start a new IV line at
another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the
site, not coolness.
52. A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion.
The nurse assesses the site and determines that phlebitis has developed. The nurse should take
which actions in the care of this client? Select all that apply.
1. Notifies the physician
2. Removes the IV catheter at that site
3. Applies warm moist packs to the site
4. Starts a new IV line in a proximal portion of the same vein
5. Documents the occurrence, actions taken, and the clients response
A. 1,2,3,5
B. 1,3,4,5
C. 1,2,3,4
D. 1,2,3,4,5
Correct Answer: 1,2,3,5
Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication)
trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The
nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to
speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the
physician about the IV complication. The nurse should restart the IV in a vein other than the one
that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the
clients response.
53. The nurse has received a prescription to transfuse a client with a unit of packed red blood
cells. Before explaining the
procedure to the client, the nurse asks which initial question?
1. Have you ever had a transfusion before?
2. Why do you think that you need the transfusion?
3. Have you ever gone into shock for any reason in the past?
4. Do you know the complications and risks of a transfusion?
Correct Answer: 1
Asking the client about personal experience with transfusion therapy provides a good starting
point for client teaching about this procedure. Options 3 and 4 are not helpful because they may
elicit a fearful response from the client. Although determining whether the client knows the
reason for the transfusion is important, option 2 is not an appropriate statement in terms of
eliciting information from the client regarding an understanding of the need for the transfusion.
54. A client has received a transfusion of platelets. The nurse evaluates that the client is
benefiting most from this therapy if the client exhibits which of the following?
1. Increased hematocrit level
2. Increased hemoglobin level
3. Decline of elevated temperature to normal
4. Decreased oozing of blood from puncture sites and gums
Correct Answer: 4
Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit
frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes.
Increased hemoglobin and hematocnt levels would occur when the client has received a
transfusion of red blood cells. An elevated temperature would decline to normal after infusion of
granulocytes if those cells were instrumental in fighting infection in the body.
55. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an
assigned client.
Approximately how long will the nurse need to stay with the client to ensure that a transfusion
reaction is not occurring?
1.5 minutes 2. 15 minutes
3. 30 minutes
4. 45 minutes
Correct Answer: 2
The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually
when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene
quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned
clients during this time. Therefore options 1, 3, and 4 are incorrect time frames.
56. The nurse listening to morning report learns that an assigned client received a unit of
granulocytes the previous evening. The nurse makes a note to assess the results of which of the
following daily serum laboratory studies to assess the effectiveness of the transfusion?
1. Hematocrit level
2. Erythrocyte count
3. Hemoglobin level
4. White blood cell
count
Correct Answer: 4
Rationale:

The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells.
These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse
notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy.
The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte
count and hemoglobin and hematocrit levels are determined after transfusion of packed red
blood cells.
57. A client is brought to the emergency department having experienced blood loss related to an
arterial laceration. Fresh- frozen plasma is prescribed and transfused to replace fluid and blood
loss. The nurse understands that the rationale for transfusing fresh-frozen plasma in this client is:
1. To treat the loss of platelets
2. To promote rapid volume expansion
3. That the transfusion must be done slowly
4. That it will increase the hemoglobin and hematocrit levels
Correct Answer: 2
Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does
not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in
clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase
the hemoglobin and hematocrit level.
58. A client requiring surgery is anxious about the possible need for a blood transfusion during or
after the procedure. The nurse suggests to the client to do which of the following to reduce the
risk of possible transfusion complications?
1. Give an autologous blood donation before the surgery.
2. Ask a friend or family member to donate blood ahead of time.
3. Take iron supplements before surgery to boost hemoglobin levels.
4. Request that any donated blood be screened twice by the blood bank.
Correct Answer: 1
A donation of the clients own blood before a scheduled procedure is autologous. Donating
autologous blood to be reinfused as needed during or after surgery reduces the risk of disease
transmission and potential transfusion complications. The next most effective way is to ask a
family member to donate blood before surgery. Blood banks do not provide extra screening on
request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful
in replacing blood lost during the surgery.
59. Which of the following fluids would be appropriate for a client who may be experiencing
excess fluid volume secondary to congestive heart failure?
1. 0.9% normal saline 2. 0.45% normal saline 3. Lactated Ringers solution 4. 5% dextrose
in 0.9% normal saline
Correct Answer: 4
The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in
0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could
then excrete the excess fluid. The 0.45% normal saline solution is hypotonic. The lactated
Ringers and 0.9% normal saline solutions are both isotonic solutions that would worsen the
excess fluid volume.
60. A client with a traumatic closed head injury shows signs that indicate the presence of
cerebral edema. Which of the
following fluids would increase cellular swelling and cerebral edema?
1. 0.9% normal saline
2. 0.45% normal saline
3. 5% dextrose in water
4. Lactated
Ringers solution
Correct Answer: 2
Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral
edema because hypotonic solutions have the potential to cause cellular swelling and cerebral
edema. The remaining choices of solutions would be appropriate because they are examples of
isotonic solutions and thus are similar in composition to plasma. These fluids would remain in the
intravascular space without potentiating the clients cerebral edema.
61. A nurse is preparing to administer a tuberculin skin test to a client via the intradermal route.
Which of the following
actions should the nurse perform when administering this test to the client?
1. Inject the medication and place a pressure dressing over the medication site.

2. Massage the area with an alcohol swab after injection to ensure that the medication is
absorbed.
3. Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle.
4. Make a circular mark around the injection site after administration of the tuberculin test.
Correct Answer: 4
An intradermal injection is administered with the needle bevel facing upward at a 10- to 15degree angle. The medication is injected slowly, and a bleb should form under the skin with
injection. After withdrawing the needle, the area may be patted dry with a 2 x 2 sterile gauze
pad, but pressure should not be applied. The area should not be rubbed because this will cause
the medication to spread beyond the area of injection. The area of injection is outlined or circled
for later reference and interpretation of the results of the test.
62. A nurse is preparing to perform an abdominal examination on a client. The nurse should
place the client in which of the following positions for this examination?
1. Supine with the head raised slightly and the knees slightly flexed
2. Semi-Fowlers position with the head raised 45 degrees and the knees flat
3. Sims position
4. Supine with the head and feet flat
Correct Answer: 1
During the abdominal examination, the client lies supine (flat on the back) with the head raised
slightly and the knees slightly flexed. This position relaxes the abdominal muscles. The abdomen
cannot be accurately assessed if the head is raised 45 degrees. Sims position is a side-lying
position and would not adequately expose the abdomen for examination. Placing the head and
feet flat would result in the abdominal muscles being taut.
63. A nurse is performing a respiratory assessment and is auscultating the clients breath
sounds. On auscultation, the
nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client
has:
1. Rhonchi 2. Crackles 3. Pleural friction rub
4. Wheezes
Correct Answer: 3
A pleural friction rub is characterized by sounds that are described as creaking, groaning, or
grating. The sounds are
localized over an area of inflammation on the pleura and may be heard in both the inspiratory
and expiratory phases of the respiratory cycle. Crackles have the sound that is heard when a few
strands of hair are rubbed together and
indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is an excessive
production of mucus
that accumulates in the air passages. Wheezes are musical noises heard on inspiration,
expiration, or both and are the result of narrowed airway passages.
64. A nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes
and do which of the
following?
1. Identify three numbers or letters traced in the clients palm.
2. Identify three objects placed in the hand one at a time.
3. State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same
place.
4. Identify the smallest distance between two detectable pinpricks, made with two pins held at
various distances.
Correct Answer: 2
Astereognosis is the inability to discern the form or configuration of common objects using the
sense of touch. Option 1 describes testing for agraphesthesia, the inability to recognize the form
of written symbols. Options 3 and 4 test for extinction phenomenon and two-point stimulation,
respectively.
65. A nurse performing a neurological examination is assessing eye movement to evaluate
cranial nerves Ill, IV, and VI.
Using a flashlight, the nurse would perform which of the following to obtain the assessment data?
1. Turn the flashlight on directly in front of the eye and watch for a response.
2. Check pupil size, and then ask the client to alternate looking at the flashlight and the

examiners finger.
3. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area
to the eye.
4. Ask the client to follow the flashlight through the six cardinal positions of gaze.
Correct Answer: 4
The nurse asks the client to follow the flashlight through the six cardinal positions of gaze to
assess for eye movement related to cranial nerves Ill, IV, and VI. Option 2 assesses
accommodation of the eye. Options 1 and 3 relate to pupillary response to light. Also shining the
light directly into the clients eye without asking the client to focus on a distant object is not an
appropriate technique.
66. The clinic nurse is preparing to provide care for a client who will need an ear irrigation to
remove impacted cerumen.
Which interventions should the nurse take when performing the irrigation? Select all that
apply.
1. Position the client to turn the head so that the ear to be irrigated is facing upward.
2. Warm the irrigating solution to a temperature that is close to body temperature.
3. Direct a slow steady stream of irrigation solution toward the upper wall of the ear canal.
4. Position the client with the affected side down after the irrigation.
5. Apply some force when instilling the irrigation solution.
Correct Answer: 2,3,4
Rationale:
During the irrigation, the client is positioned so that the ear to be irrigated is facing downward
because this allows gravity to assist in the removal of the earwax and solution. Delivery of
irrigation solutions at temperatures that are not close to body temperature can cause discomfort
for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of
solution should be directed toward the upper wall of the ear canal, not toward the tympanic
membrane. After the irrigation, the client should lie on the affected side for a period of time that
is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too
much force could cause the tympanic membrane to rupture.
67. A nursing student is performing an otoscopic examination in an adult client. The nursing
instructor observes the student perform this procedure. Which observation by the instructor
indicates that the student is using correct technique for the procedure?
1. Pulling the pinna down and back before inserting the speculum
2. Pulling the earlobe down and back before inserting the speculum
3. Using the smallest speculum available
4. Tilting the clients head slightly away and holding the otoscope upside down before inserting
the speculum
Correct Answer: 4
Rationale:
In the otoscopic examination, the nurse tilts the clients head slightly away and holds the
otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse
visualizes the external canal while slowly inserting the speculum. A small speculum is used in
pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small
speculum is used in the adult client.
68. A nurse is preparing to perform a Weber test on a client. The nurse obtains which item
needed to perform this test?
1. A tongue blade
2. A stethoscope
3. A tuning fork
4. A reflex hammer
Correct Answer: 3
A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating
tuning fork at the midline of the clients forehead or above the upper lip over the teeth. Normally
the sound is heard equally in both ears by bone conduction. If the client has a sensorineural
hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing
loss in one ear, the sound is heard in that ear. The items identified in options 1, 2, and 4 are not
needed to perform the Weber test.
69. A client arrives at the emergency department with a foreign body in the left ear and tells the
nurse that an insect flew into the ear. Which intervention should the nurse implement initially?

1. Irrigation of the ear

2. Instillation of mineral oil

3. Instillation of antibiotic eardrops

4. Instillation of corticosteroid ointment

Correct Answer: 2
Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming
noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is
then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not
used because such material may expand with hydration, thereby worsening the impaction. The
actions identified in options 3 and 4 are not initial nursing actions.
70. A nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor
asks the student to describe the physiology associated with this diagnosis. The nursing instructor
determines that the student understands this condition if the student states that presbycusis is:
1. A loss of vision associated with aging
2. A loss of balance that occurs with aging
3. A sensorineural hearing loss that occurs with aging
4. A conductive hearing loss that occurs with aging
Correct Answer: 3
Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss
caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 4 are
incorrect descriptions of this condition.
71. A nurse is caring for a client with acute otitis media. In order to reduce pressure and allow
fluid to drain, the nurse
anticipates that which of the following would most likely be recommended to the client?
1. The administration of diphenhydramine (Benadryl) capsules
2. A myringotomy
3. Strict bed rest
4. A mastoidectomy
Correct Answer: 2
Rationale:
A myRIngotomy is a surgical procedure that will allow fluid to drain from the middle ear. Benadryl
is an antihistamine with antiemetic properties. Strict bedrest is not necessary, although activity
may be restricted. Additionally, bedrest would not assist in reducing pressure or allowing fluid to
drain. In some cases, the mastoid bone is removed or partially removed for chronic otitis media.
72. A nursing student is assigned to administer an iron injection to a client. The co-assigned
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:
1. Anterolateral thigh using an air lock
2. Gluteal muscle using Z-track technique
3. Subcutaneous tissue of the abdomen using a 1-inch needle
4. Deltoid muscle using a 1-inch needle
Correct Answer: 2
The correct technique for administering parenteral iron is deep in the gluteal muscle using Ztrack technique. This method minimizes the possibility that the injection will stain the skin a dark
color. The medication is not given by the subcutaneous route, nor is it given in the arms,
abdomen, or thighs.
73. A clinic nurse is performing a cardiovascular assessment on a client. In preparing to assess
the clients apical pulse,
the nurse places the stethoscope over the hearts apex in which of the following positions?
1. At the midline of the chest just below the xiphoid process
2. At the midclavicular line at the fifth left intercostal space
3. At the midaxillary line on the left side of the chest
4. Midsternum, equal with the nipple line
Correct Answer: 2
The heart is located in the mediastinum. Its apex, or distal end, points to the left and lies at the
level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart
sounds most clearly. The other options are incorrect because they do not represent the
anatomical positioning of the hearts apex.

74. A clinic nurse is preparing to perform a Romberg test on a dient being seen in the clinic. The
nurse performs this test
for the purpose of determining:
1. The clients ability to ambulate
2. The functional status of the vestibular apparatus in the inner ear
3. The intactness of the retinal structure of the eye
4. The intactness of the tympanic membrane
Correct Answer: 2
The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help
maintain standing balance.
The Romberg test also assesses intactness of the cerebellum and proprioception. Options 1, 3,
and 4 are incorrect.
75. A client has an order for an injection to be administered by the intraderrnal route. The nurse
avoids which of the
following actions when administering this medication?
1. Inserting the needle at a 10- to 15-degree angle
2. Injecting the medication slowly
3. Massaging the area after removing the needle
4. Making a circular mark around the injection site
Correct Answer: 3
An intradermal injection is administered with the needle bevel facing upward at a 10- to 15degree angle. The medication is injected slowly, and a bleb should form under the skin with
injection. After withdrawal of the needle, the area may be patted dry with a 2 x 2 sterile gauze.
The area should not be rubbed, to prevent the spread of the medication beyond the area of
injection. All equipment is then disposed of, and the area of injection is outlined (circled) for later
reference.
76. A nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which
of the following areas
least helpful in assessing for pallor or cyanosis?
1. Sclera
2. Tongue
3. Mucous membranes
4. Nailbeds
Correct Answer: 1
Skin color may be more difficult to assess in the client with dark skin. The best areas to use to
detect pallor and cyanosis include the tongue, mucous membranes, and the nailbeds. The
sclerae are most useful in evaluating jaundice.
77. A nurse instructs a client in the use of a hearing aid. The nurse includes which of the
following instructions?
1. Check the battery to ensure that it is working before use.
2. Leave the hearing aid in place while showering.
3. Hearing aids do not require any care.
4. A water-soluble lubricant is used on the hearing aid before insertion.
Correct Answer: 1
The battery of the hearing aid should be checked before use. The hearing aid should be removed
for showering because it should not get excessively wet. It also should be put away in its case at
night. It should be cleaned according to the manufacturers directions, which usually consist of
cleaning the ear mold with mild soap and water (avoiding excessive wetness), followed by
thorough drying. Lubricants or other solvents are not used on the hearing aid.
78. A nurse is performing a physical examination of the client. The nurse selects which of the
following items to test the
function of cranial nerve II (optic nerve)?
1. Flashlight 2. Ophthalmoscope
3. Reflex hammer 4. Snellen chart
Correct Answer: 4
Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a
Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve
function is a Rosenbaum card to evaluate near vision. This card is a hand-held card used to test
visual acuity; the nurse records the smallest line seen as well as the distance that the card is
held from the client. A flashlight is used to test the pupillary reaction. An ophthalmoscope is used
to examine the retina. A reflex hammer is used to test reflexes.
79. A nurse notes that a clients parenteral nutrition solution is 4 hours behind. The nurse should

take which action?

1. Administer the parenteral nutrition solution using gravity flow because the infusion pump is
malfunctioning.
2. Replace the parenteral nutrition solution with 10% dextrose and restart the solution the
following day.
3. Assess the infusion pump to be sure it is functioning properly and is set at the correct rate.
4. Increase the infusion rate to a rate that allows the infusion volume to correct itself within a 2hour period.
Correct Answer: 3
If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch
up, because a hyperosmotic reaction among other reactions could result. The solution should not
be replaced by another or restarted the next day. An infusion pump should always be used to
administer parenteral nutrition solution.
80. A nurse is caring for a restless client who is beginning nutritional therapy with parenteral
nutrition (PN). The nurse
should plan to ensure that which of the following is done to prevent the client from injury?

1. Calculate daily intake and output.

2. Monitor the temperature once daily.
3. Secure all connections in the PN system.

4. Monitor blood glucose levels every 12

hours

Correct Answer: 3
Rationale:
The nurse should plan to secure all connections in the tubing (tape is used per agency protocol).
This helps prevent the restless client from pulling the connections apart accidentally. The nurse
should also monitor intake and output, but this does not relate specifically to a risk for injury as
presented in the question. Also, options 2 and 4 do not relate to a risk for injury as presented in
the question. In addition, the clients temperature and blood glucose levels are monitored more
frequently than the timeframes identified in the options to detect signs of infection and
hyperglycemia, respectively.
81. Contact precautions are initiated for a client with a health careassociated (nosocomial)
infection caused by methicillinr esistant Staphylococcus aureus. The nurse prepares to provide
colostomy care and obtains which of the following protective items needed to perform this
procedure?

1. Gloves and gown

2. Gloves and goggles

3. Gloves, gown, and shoe protectors

4. Gloves, gown, goggles, and face shield

Correct Answer: 4
Splashes of body secretions can occur when providing colostomy care. Goggles and a face shield
are worn to protect the mucous membranes of the eyes during interventions that may produce
splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require
the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe
protectors are not necessary.
82. A client is being prepared for a thoracentesis. A nurse assists the client to which position for
the procedure?
1. Lying in bed on the affected side
2. Lying in bed on the unaffected side
3. Sims position with the head of the bed flat
4. Prone with the head turned to the side and supported by a pillow
Correct Answer: 2
To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed
leaning over the bedside table, with the feet supported on a stool or lying in bed on the
unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims
positions are inappropriate positions for this procedure.
83. A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in

which position for insertion?

1. Right side
2. Low Fowlers
3. High Fowlers
4. Supine with the head
flat
Correct Answer: 3
During insertion of a nasogastric tube, the client is placed in a sitting or high Fowlers position to
reduce the risk of pulmonary aspiration if the client should vomit. Options 1, 2, and 4 will not
facilitate insertion of the tube or prevent aspiration.
84. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which
is the best position in
which the nurse should place the client?

1. Side-lying on the operative side

2. On the nonoperative side with the legs
abducted
3. Side-lying with the affected leg internally

rotated
4. Side-lying with the affected leg externally
rotate

Correct Answer: 2
Positioning following a total hip replacement depends on the surgical techniques used, the
method of implantation, the prosthesis, and physicians preference. Abduction is maintained
when the client is in a supine position or positioned on the nonoperative side. Internal and
external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by
the physician) is avoided. Options 1, 3, and 4 are incorrect positions for this client.
85. 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?
1. Left Sims position
2. Right Sims position
3. On the left side of the body, with the head of the bed elevated 45 degrees
4. On the right side of the body, with the head of the bed elevated 45 degrees
Correct Answer: 1
For administering an enema, the client is placed in a left Sims position so that the enema
solution can flow by gravity in
the natural direction of the colon. The head of the bed is not elevated in the Sims position.
86. A nurse is preparing to remove a nasogastric tube from a client. The nurse should instruct the
client to do which of the following just before the nurse removes the tube?

1. Exhale.
2. Inhale and exhale quickly.

3. Take and hold a deep breath.

4. Perform a Valsalva maneuver

Correct Answer: 3
When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep
breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into
the nose. The nurse removes the tube with one smooth, continuous pull. Therefore, options 1, 2,
and 4 are incorrect.
87. A nurse is preparing to administer medication through a nasogastnc tube that is connected to
suction. To administer
the medication, the nurse would:
1. Position the client supine to assist in medication absorption.
2. Aspirate the nasogastric tube after medication administration to maintain patency.
3. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.
4. Change the suction setting to low intermittent suction for 30 minutes after medication
administration.
Correct Answer: 3
If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes
before reconnecting the tube to the suction apparatus to allow adequate time for medication
absorption. Aspirating the nasogastric tube will

remove the medication Just administered. Low intermittent suction also will remove the
medication just administered. The client should not be placed in the supine position because of
the risk for aspiration.
88. A nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the
stomach contents and
checks the contents for pH. The nurse verifies correct tube placement if which pH value is noted?
1. 3.5
2. 7.0
3. 7.35
4. 7.5
Correct Answer: 1
If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates
have acidic pH values and should be 3.5 or lower. Option 2 indicates a slightly acidic pH. Option 3
indicates a neutral pH. Option 4 indicates an alkaline pH.
89. A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct
the client to:

1. Exhale slowly.
2. Stay very still.

3. Inhale and exhale quickly.

4. Perform the Valsalva maneuver

Correct Answer: 4
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a
deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is
taped in place. An alternative instruction is to ask the client to take a deep breath and hold the
breath while the tube is removed. Options 1, 2, and 3 are incorrect client
instructions.
90. A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle
bubbling in the suction control chamber. What action is appropriate?
1. Do nothing, because this is an expected finding.
2. Immediately clamp the chest tube and notify the physician.
3. Check for an air leak because the bubbling should be intermittent.
4. Increase the suction pressure so that the bubbling becomes vigorous.
Correct Answer: 1
Continuous gentle bubbling should be noted in the suction control chamber. Option 2 is in
correct. Chest tubes should only be clamped to check for an air leak or when changing drainage
devices (according to agency policy). Option 3 is incorrect. Bubbling should be continuous in the
suction control chamber and not intermittent. Option 4 is incorrect
because bubbling should be gentle. Increasing the suction pressure only increases the rate of
evaporation of water in the drainage system.
91. A nurse is assessing the functioning of a chest tube drainage system in a client who has just
returned from the recovery room following a thoracotomy with wedge resection. Select the
expected assessment findings. Select all that apply.
a. 3,4,5,6
b. 1,2,3,4
c. 2,3,4,5
d. 1,2,3,4,5,6
1. Excessive bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. 50 mL of drainage in the drainage collection chamber
4. Drainage system maintained below the clients chest
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
Correct Answer: 3,4,5,6
Rationale:
The bubbling of water in the water seal chamber indicates air drainage from the client and
usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur
during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may
indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal
chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate
that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking

into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control
chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit
from the recovery room. Drainage that is more that 70 to 100 mLihr is considered excessive and
requires physician notification. The chest tube insertion site is covered with an ocdusive (airtight)
dressing to prevent air from entering the pleural space. Positioning the drainage system below
the clients chest allows gravity to drain the pleural space.
92. The home care nurse is performing an environmental assessment in the home of an older
client. Which of the following, if observed by the nurse, requires immediate attention?
1. Unsecured scatter rugs
2. Clear exit passageways
3. An operable smoke detector
4. A prefilled medication cassette
Correct Answer: 1
Rationale:
Trauma to the older client in the home may be caused by a variety of factors. These include an
unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke
detectors, and a history of previous falls.
93. A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the
nurse inflates the balloon, the
client complains of discomfort. The appropriate nursing action is to:
1. Aspirate the fluid, remove the catheter, and insert a new catheter.
2. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
3. Remove the syringe from the balloon; discomfort is normal and temporary.
4. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
Correct Answer: 2
Rationale:
If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain
will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther
into the bladder to provide sufficient space to inflate the balloon. The balloon of the catheter is
behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that
the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the
catheter and insert a new one. Pain when the balloon is inflated is not normal.
94. A nurse is inserting an indwelling urinary catheter into a male client. As the catheter is
inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse:
1. Immediately inflates the balloon
2. Inserts the catheter 2.5 to 5 cm and inflates the balloon
3. Withdraws the catheter about 1 inch and inflates the balloon
4. Inserts the catheter until resistance is met and inflates the balloon
Correct Answer: 2
The balloon of the urinary catheter is behind the opening at the insertion tip. The catheter is
inserted 2.5 to 5 cm after urine begins to flow to provide sufficient space to inflate the balloon.
Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder
and not in the urethra. Inflating the balloon in the urethra could produce trauma.
95. A nurse is preparing to care for a client with esophageal vances who has just had a
Sengstaken-Blakemore tube
inserted. The nurse gathers supplies, knowing that which of the following items must be kept at
the bedside at all
times?
1. An obturator
2. A Kelly clamp
3. An irrigation set 4. A pair of scissors
Correct Answer: 4
The Sengstaken-Blakemore tube is a triple-lumen gastric tube that may be used to treat bleeding
esophageal varices if other interventions are contraindicated or are ineffective. The tube has an
inflatable esophageal balloon, an inflatable gastric balloon, and a gastric aspiration lumen. The
gastric balloon applies pressure at the cardioesophageal junction to compress gastric varices
directly and to decrease blood flow to esophageal varices; traction is applied to maintain the
gastric balloon in place.
When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the clients

bedside at all times. The client needs to be observed for sudden respiratory distress, which
occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse
immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are
kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside,
but it is not the priority item.
96. Two nurses are leaving a clients 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?
1. Removing the gown without rolling it from inside out
2. Taking off the gloves first before removing the gown
3. Washing the hands after the entire procedure has been completed
4. Removing the gloves and then removing the gown using the neck ties
Correct Answer: 1
Rationale:
The gown must be rolled from inside out to prevent the organisms on the outside of the gown
from contaminating other areas. Gloves are considered the dirtiest piece of equipment and
therefore must be removed first. Hands must be washed after removal of the protective garb to
remove any unwanted germs still present. Ungloved hands should be used to remove the gown
to prevent contaminating the back of the gown with germs from the gloves.
97. A nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The
client has right-sided arm and leg weakness. The nurse suggests that the client use which of the
following assistive devices to provide the best stability for ambulating?

Correct Answer: 3
Rationale:
Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A
cane is better suited for the client with weakness of the arm and leg on one side; however, the
quad cane would provide the most stability because of the structure of the cane and because a
quad cane has four legs.
98. A nurse is instructing a client who had a stroke and has weakness on one side how to
ambulate with the use of a cane.
Which of the following instructions should the nurse provide to the client?
1. Hold the cane on the affected (weak) side.
2. Hold the cane on the unaffected (strong) side.
3. Move the cane forward first along with the unaffected (strong) leg.
4. Move the cane and the unaffected (strong) leg down first when going down stairs.
Correct Answer: 2
Rationale:
The cane is kept on the strong side of the body. It would be hard to hold the cane on the weak
side. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right
after it, in ambulating or in going down stairs.
99. The home care nurse visits a client at home who has been experiencing increased weakness.
The client tells the nurse
that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses
the clients use of the
cane and determines that the cane is sized correctly if:
1. The handle of the cane is even with the clients waist.
2. The clients elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.
3. The clients elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.
4. The clients elbow is straight when ambulating with the cane.
Correct Answer: 2
The height of a cane should be even with the greater trochanter. This allows the elbow to be held
at approximately 15
to 30 degrees of flexion. The flexion is necessary to allow the client to push off without bending
over when ambulating.
Options 1, 3, and 4 are incorrect and present an unsafe situation.
100. A home care nurse visits a client who has been started on oxygen therapy. The nurse
provides instructions to the client
regarding safety measures for the use of oxygen in the home. Which statement, if made by the
client, indicates a need
for further instruction?
1. I need to be sure that no one smokes in my home.
2. I need to be sure that I stay at least 10 feet away from any burning candles.
3. It is all right to use an electric razor for shaving only if I leave it plugged in for a short time.
4. I need to be sure that there is space between the oxygen concentrator and the wall in the
room.
Correct Answer: 3
The use of small electric items, tools, or other equipment could emit sparks and should be
avoided while oxygen is in use. The use of this equipment could result in fire and injury to the
client. The oxygen concentrator is kept away from walls and corners to permit adequate airflow.
The client also should be instructed not to allow smoking in the home and to stay at least 10 ft
away from any type of flame.