1.

Which of the following disorders is characterized by joint inflammation that is usually accompanied by pain and frequently accompanied by changes in structure? a. Synovitis b. Arthritis c. Bursitis d. Tendinitis 2. Which term refers to the expectoration of blood from the respiratory tract? a. A hemorrhage b. Hematopoiesis c. Hemoptysis d. Hemopexis 3. Which term describes lack of coordination in performing planned, purposeful movements, resulting from a neurologic deficit? a. Apraxia b. Ataxia c. Fasciculation d. Myokymia 4. An elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2) indicates that the patient has: a. Hypernatremia b. Hypocalcemia c. Hypoxemia d. Hypercapnia 5. The latest laboratory values indicate that the patient has thrombocytopenia. The combining form penia means: a. Rupture b. Deficiency c. Formation d. Stupor 6. A patient is admitted to the hospital with a urine specific gravity of 1.030, a temperature of 102F (38.9 C), and flushed, dry skin. Based on these data, the nurse writes which of the following nursing diagnoses? a. Potential for impaired skin integrity b. Fluid volume deficit related to fever c. Potential for fluid volume deficit caused by fever d. Altered cardiopulmonary tissue perfusion related to fluid excess 7. The guidelines for writing an appropriate nursing diagnosis include all of the following except: a. State the diagnosis in terms of a problem, not a need b. Use nursing terminology to describe the patients response c. Use statements that assist in planning independent nursing interventions d. Use medical terminology to describe the probable cause of the patients response 8. Based on a physicians order for oxygen by nasal catheter at 3 liters/ minute, an appropriate nursing order would be: a. Cover the tip of the catheter with a water-soluble lubricant before insertion. b. Measure the length of the catheter from the tip of the patients nose to the tip of the earlobe before insertion c. Add sterile distilled water to the humidification container, as needed d. All of the above 9. A nurse observes a dazed and apparently confused co-worker taking two diazepam (Valium) tablets by mouth as the co-worker is about to pour medications. What should the nurse do? a. Call the head nurse immediately before the co-worker pours and administers the medications b. Pour the medications for the co-worker while she goes for a cup of coffee c. Report the co-worker to hospital security because she may be addicted to drugs d. Watch the co-worker closely and report the incident to the head nurse at the end of the day. 10. A nurse manager notices that one of the staff nurses is always 15 to 20 minutes late. When the nurse manager discusses the problem with her, the nurse says that she has been late because her

sons nursery school does not open until 7 am. The nurse manager should respond by telling her to: a. Ask one of the night nurses to cover for her b. See if a neighbor can take the child to school c. Find out if other schools open earlier d. Find some way to solve the problem and be on time 11. A nurse has just moved to a new state, where she has accepted employment in a hospitalbased hemodialysis unit. She needs information about her specific duties in caring for hemodialysis patients. She will find this information in: a. Policy statements set by the National Kidney Foundation b. The states nurse practice act c. Medicare and Medicaid regulations d. The hospitals procedure manual 12. Which of the following is an example of nursing malpractice? a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor 13. Therapeutic communication is a significant aspect of patient care. Which of the following statements most clearly defines this concept? a. Therapeutic communication conveys feelings of warmth, acceptance, and empathy from the nurse to the patient in a nonjudgmental atmosphere b. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals c. Therapeutic communication is the assessment component of the nursing process, in which the nurse gathers health history information from the patients perspective d. Therapeutic communication is an interactional process in which the nurse purposefully reviews and assesses the conversation and its potential outcomes 14. Many factors can become barriers to communication. In which of the following situations would communication least likely be hindered? a. Mr. S., a 30-year-old Vietnamese immigrant, is admitted to the hospital with a fractured tibia; he speaks limited English b. Ms. M., age 58 and unmarried, is admitted to the hospital for breast surgery c. Mrs. R, age 26, is admitted to the hospital for a scheduled cesarean section; this is her first admission d. Mr. G., age 78, arrives at the hospital by ambulance after suffering a stroke at home 15. The assessment component of the nursing process requires effective communication to elicit a complete, relevant history from the patient and to identify patient problems. What role does communication play in the other areas of the nursing process? a. In the planning phase, effective therapeutic communication helps to establish nursing care priorities and patient-oriented goals b. During the implementation phase, communication skills allow the nurse to assess the patients response to planned interventions c. During the evaluation phase, effective communication allows the nurse to find out from the patient if he is responding to treatment or if changes in treatment are necessary d. All of the above 16. All of the following would be considered objective assessment data for a patient admitted with diabetes mellitus except: a. + 2 urine glucose level; negative urine acetone level b. Chemstrip reading of 240 mg/dl c. Patient complaints of polydipsia d. Serum glucose level of 263 mg/dl

17. Which of the following statements about bowel sounds is accurate? a. Peristalsis causes bowel sounds b. Rapid, high-pitched, hyperactive bowel sounds indicate increased peristalsis c. Decreased bowel sounds can be a symptom of paralytic ileus d. All of the above 18. Independent nursing intervention commonly used for immobilized patients include all of the following except: a. Active or passive ROM exercises, body repositioning, and activities of daily living (ADLs) as tolerated b. Deep-breathing and coughing exercises with change of position every 2 hours c. Diaphragmatic and abdominal breathing exercises and increased hydration d. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy 19. Independent nursing interventions commonly used for patients with pressure ulcers include: a. Changing the patients position regularly to minimize pressure b. Applying a drying agent such as an antacid to decrease moisture at the ulcer site c. Debriding the ulcer to remove necrotic tissue, which can impede healing d. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated 20. A female patient has gained 24 lb after being admitted to the hospital. Im such a horse; I just cant stand myself like this, she tells the nurse. After assessing the patient, the nurse writes the following nursing diagnosis: Body image disturbance. To arrive at this diagnosis, the nurse should include which of the following assessment findings? a. The patients perception of her body before the hospitalization and weight gain b. The significance the patient places on these changes c. The patients feelings about her body d. All of the above 21. Stressors cause the release of the mineralocorticoid aldosterone, which regulates sodium absorption and potassium excretion in the renal tubules, resulting in: a. The need for supplemental potassium b. The need for a low-sodium (500-mg) diet c. The conservation of water and maintenance of blood volume d. Increased diuresis 22. In planning the care of a patient who is exposed to multiple stressors such as separation from loved ones, anxiety about impending surgery, and concern about potential complications or death, the nurse must: a. Use both a structured and an unstructured format when interviewing the patient b. Know the stressors affecting the patient c. Develop the expected outcomes for each nursing diagnosis written for this patient d. All of the above 23. An accurate method of calculating the daily urine output of an incontinent patient wearing pads or diapers is to: a. Estimate the urine output b. Count the number of urine saturated pads c. Weigh a dry pad and each urine saturated pad and use a conversion calibration to calculate the urine output d. Weigh all the urine-saturated pads together and use a conversion calibration to calculate the urine output 24. A fashion model is admitted via the emergency room with facial and chest burns. Her hospital stay includes 10 days in the intensive care unit and 5 days on the regular hospital unit. The patient has not been eating or sleeping and refuses to perform her activities of daily living (ADLs). She refuses to work with speech and physical therapists. Which of the following nursing diagnoses might appears on the patients current care plan? a. Potential for noncompliance: Self-harm related to disturbed body image b. Self-care deficit related to knowledge deficit and disturbed body image c. Disturbance in self-concept: Personal identifying related to self-esteem d. Disturbance in self-concept related to altered thought process 25. White the nurse is providing a patients personal hygiene, she observes that his skin is

excessively dry. During this procedure the patient tells her that he is very thirsty. An appropriate nursing diagnosis would be: a. Potential for impaired skin integrity related to altered gland function b. Potential for impaired skin integrity related to dehydration c. Impaired skin integrity relate to dehydration d. Impaired skin integrity related to altered circulation 1. Answer B. Arthritis is characterized by joint inflammation that is usually accompanied by pain and frequently accompanied by changes in structure. Synovitis is the inflammation of the synovial membrane, typically resulting from a traumatic injury or an aseptic wound. Bursitis is the inflammation of a bursa, typically one located between a bony prominence and a muscle or tendon. Tendinitis is the inflammation of tendon. 2. Answer C. Hemoptysis is the expectoration of blood from the respiratory tract. A hemorrhage is abnormal internal or external bleeding. Hematopoiesis is blood cell formation. Hemopexis is blood coagulation. 3. Answer B. Ataxia is lack of coordination in performing planned, purposeful movements, typically resulting from a neurologic deficit. Apraxia is the inability to perform purposeful movements even though no neuromuscular deficit exists. Fasciculations are fine twitching movements. Myokymia is a transient, spontaneous movement that occurs in muscle groups after strenuous exercise. 4. Answer D. Hypercapnia is an elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2). Hypernatremia is an elevated level of sodium in venous blood (more than 145 mEq/liter). Hypocalcemia is a decreased level of calcium in venous blood (less than 9 mg/dl). Hypoxemia is a reduced level of oxygen in arterial blood (less than 80 mm Hg while breathing room air). 5. Answer B. The combining form penia means deficiency, as in thrombocytopenia (deficiency in the number of circulating blood plates). Rrhexis is a combining form meaning rupture, as in enterorrhexis (rupture of the intestine). Plast is a combining form meaning formation, as in rhinoplasty (formation of a nose using plastic surgery). Narco is a combining form meaning stupor, as in narcolepsy (a condition marked by recurrent attacks of drowsiness and sleep). 6. Answer B. Fluid volume deficit related to fever is the appropriate nursing diagnosis based on this assessment. Potential for impaired skin integrity states a possible patient response. Potential for fluid volume deficit caused by fever implies a cause-and-effect relationship, which a nursing diagnosis should never do. Altered cardiopulmonary tissue perfusion related to fluid excess is an incorrect diagnosis based on a misinterpretation of the data. 7. Answer D. A nursing diagnosis is a statement about a patients actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never a part of the nursing diagnosis. An appropriate nursing diagnosis would be ineffective breathing pattern related to chest pain rather than ineffective breathing pattern caused by angina. 8. Answer D. A water-soluble lubricant must be applied to the tip of the catheter to decrease friction and the risk of injury to the patients nasal mucosa. (If petrolatum or mineral oil were applied to the catheter and then aspirated, the patient could develop a lipoid pneumonia) The distance from the tip of the nose to the tip of the earlobe is the approximate distance from the point of insertion to the oropharynx. Sterile distilled water must be used to humidity the oxygen because oxygen administered by itself is a dry gas that can irritate the mucosa. 9. Answer A. Patient safety is the major concern in this situation. According to the International Council of Nurses Code for Nurses: The nurse [should] take appropriate action to safeguard the individual when his or her care is endangered by a co-worker or any other person. In this case, talking with the head nurse immediately would be the best way to safeguard the patients safety. The nurse isnt necessarily an addict, she may be abusing a prescription medication. 10. Answer D. It is the staff nurses responsibility to be on time. The nurse manager should not assume a responsibility that belongs to the nurse. 11. Answer D. Although Medicare and Medicaid regulations and suggestions made by such groups as the National Kidney Foundation may serve as guidelines, a hospitals procedure manual details how the nurse should perform her specific duties. A states nurse practice act defines the

scope of practice within that state, but not the specifics for each area of practice. 12. Answer A. The three elements necessary to establishes nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or healing pad to a patient without a physicians order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. 13. Answer B. Therapeutic communication is a two way, deliberative interaction between the patient and nurse in which they establish mutually acceptable, achievable goals of care. Before the patient can feel comfortable discussing his problems, however, and atmosphere of trust and acceptance must be established. 14. Answer C. Many variables affect patient nurse communication, including the patients cultural beliefs, experiences with hospitalization, age, emotional needs, and problems with speech, hearing, or comprehension. A patient admitted to the hospital for the first time for a scheduled cesarean section is probably anxious, but she had time to plan for the procedure, does not bring negative experiences from previous hospitalizations, and in most cases looks forward to the birth. 15. Answer D. Therapeutic communication is a fundamental component at all phases of the nursing process. In the planning phase, it allows the patient and nurse to formulate mutually acceptable and patient-oriented goals, which are the basis for developing an individualized care plan. In the implementation phase, effective communication is necessary for teaching the patient, motivating him to achieve goals, and assessing patient outcomes. Finally, in the evaluation phase, it is required to determine how well the patient has responded to interventions. 16. Answer C. Objective data are those which can be measured, like glucose levels. A complaint of polydipsia is subjective information obtained from the patient. 17. Answer D. Peristalsis is the muscular, rhythmic movement in the bowel wall that pushes food along the digestive tract distally. Increased bowel motility is indicated by rapid, high-pitched, hyperactive bowel sounds. Decreased bowel sounds, caused by decreased bowel motility, can be the initial sign of paralytic ileus (adynamic intestinal obstruction resulting from the lack of peristalsis), a common occurrence following abdominal surgery. 18. Answer D. The use of a tilt table for weight-beating exercises, parenteral nutrition, and vitamin therapy are not independent nursing interventions because they require a physicians order. Unless specifically contraindicated, the independent nursing interventions listed in A, B, and C may be part of the nursing care plan for an immobilized patient. 19. Answer A. Independent nursing interventions for a patient with pressure ulcers commonly include changing his position several times each day to avoid pressure to any part of his body, especially the involved area. Drying agents, which are prescribed by a physician, are contraindicated because wounds need moisture to heal. Whirlpool therapy and chemical debridement must be prescribed, and surgical debridement is done by the physician. 20. Answer D. All of the choices will help the nurse determine the extent of the problem. For example, asking how the patient felt about her body before hospitalization will help the nurse determine whether the disturbed body image is a crisis brought on by the weight gain or a longstanding problem. Asking what the change means to her will reveal whether she feels she has control over what is happening or believes the change is permanent. Body image is also related to how we think we compare to others or whether others find us attractive. 21. Answer C. Because aldosterone regulates the bodys sodium and potassium levels, it acts as an adaptive mechanism in maintaining blood volume and conserving water. Supplemental potassium usually is given to a patient with a low serum potassium level or one who is receiving a diuretic or other medication such as digoxin that has a mild diuretic effect. A low-sodium diet is usually prescribed for a patient with a high serum sodium level, as in congestive heart failure (CHF), hypertension, or prolonged episodes of edema. Diuresis is increased naturally when a healthy patient increases his intake of fluids, especially those containing caffeine. Patients receiving diuretics also experience increased diuresis. 22. Answer D. Interviewing the patient in both a structured and an unstructured format is an important part of the initial nursing assessment. The structured format uses questions that require a

yea-or-no answer to help the nurse obtain information; the unstructured format uses open-ended questions that allow the patient to express himself more fully. The interview helps the nurse and patient identify the stressors and develop appropriate outcomes. 23. Answer C. Calculating the difference in weight between a dry pad and a urine saturated pad using conversion calibration will provide an accurate measure of urine output. For example, if the difference between the dry pad and the urine-saturated pad is 200 g, the urine output would be 200 ml (1g = 1 ml). The other methods will provide only an estimate of urine output. 24. Answer C. Disturbances in self-concept may manifest themselves as signs and symptoms of depression, such as changes in sleep patterns, eating habits, and energy levels. The other nursing diagnoses are not supported by the given situation. 25. Answer C. An appropriate nursing diagnosis for a patient with excessively dry skin is Impaired skin integrity (actual not potential) in this case, related to dehydration because the patient complains of thirst. Altered circulation is not usually an etiologic factor for dry skin. foundation of nursing ncles test review Situation: One important legal and safe nursing responsibility is concerned with administration of medications. 1. A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops 4 times a day. The nurse should administer the medication on to which of the following areas? a. Center of the cornea b. Sclera by the inner canthus c. C. Sclera by the outer canthus d. Lower conjunctival sac 2. While assessing the clients intravenous (IV) line, the nurse notes that the area is swollen and cool, causing the client discomfort. The nurse suspects which of the following problems: a. Infiltration b. Phlebitis c. Infection d. Air embolism 3. The client is receiving a 5% dextrose in 0.45% NaCl intravevenously (IV) and report pain at the site, the nurse assesses the site and notes erythema and edema. What would be the appropriate action for the nurse to take? a. Slow the infusion rate b. Discontinue the IV and apply a warm compress to the IV site c. Apply antibiotic ointment to the IV site d. Gently pull back the IV access device to reposition it within the vein 4. A patients medication order is to take digoxin 0.125 mg p.o. q.i.d. The nurse has on hand Lanoxin 0.25 mg tablet. The best course of action is to: a. Dispense 1 tab b. Dispense tab c. Dispense 2 tablets d. Return the medication to the pharmacy 5. The patient is ordered 2000 ml of Lactated Ringers over 12 hours. The drop factor is 15gtts/ml. The nurse will regulate the IV to how many gtts/min? a. 28 gtts/min b. 42 gtts/min c. 56 gtts/min d. 14 gtts/min Situation: The nurse is caring for a group of hospitalized patients. 6. What should the nurse do first to prevent patient infections? a. Provide small bedside bags to dispose of used tissues b. Encourage staff to avoid coughing near patients c. Administer antibiotics as ordered d. Identify patients at risk 7. The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique?

a. Stool for ova and parasites b. Specimen for a throat culture c. Urine from a retention catheter d. Exudate from a wound for culture and sensitivity 8. The nurse identifies that the greatest risk for a wound infection exists for a patient with a: a. Surgical creation of a colostomy b. First degree burn on the back c. Puncture of a foot by a nail d. Paper cut on the finger 9. The nurse understands that the factor that places a patient at the greatest risk for developing an infection is: a. Implantation of a prosthetic device b. Presence of an indwelling catheter c. Burns more than twenty percent of the body d. Multiple puncture sites from laparascopic surgery 10. The nurse is caring for a patient with high fever secondary septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieved heat loss via: a. Radiation b. Convection c. Conduction d. Evaporation Situation: The nurse is caring for Mrs. Estrada who has recently diagnosed with advanced cancer. 11. Which statement reflects Kubler-Ross stage of denial in the grief process? a. Why this have to happen to me now? b. My daughter will live with my sister after I am gone c. Maybe they mixed up my records with someone elses d. How could this happen to me when I quit smoking cigarettes? 12. After the physician has informed Mrs. Estrada that her cancer is inoperable and the prognosis is poor, the patient begins to cry. The nurse should: a. Touch the patients hand to provide support b. Leave the room to give the patient privacy to cry c. Telephone the patients family to inform them of the diagnosis d. Ask the patient how she feels to encourage ventilation of feelings 13. Mrs. Estrada became withdrawn and depressed. The nursing action that is most therapeutic is: a. Assisting the patient to focus on positive thoughts daily b. Explaining that the patient still accomplish goals c. Accepting the patients behavioral adaptation d. Offering the patient advice when appropriate 14. Which is the most appropriate inference made by the nurse when a patient says, Im the same age as my father when he died. Am I going to die of my cancer? The patient is experiencing: a. Grieving associated with perceived impending death b. Powerlessness associated with feelings of loss of control c. Fear associated with perceived threat to biological integrity d. Ineffective coping associated with inadequate psychological resources 15. Mrs. Estrada is now willing to try new therapies. The nurse identifies that the patient is in what stage of Kubler-Ross stages of grieving? a. Denial b. Bargaining c. Depression d. Acceptance Situation: The nurse should be aware of the legal principles associated with nursing practice. 16. Licensure of Registered Professional Nurses is required necessarily to protect: a. Nurses b. Patients c. Common law

d. Health care agencies 17. A patient falls while getting out of bed unassisted. When completing and Incident Report, the nurse understands that it main purpose is to: a. Ensure that all parties have an opportunity to document what happened b. Help establish who is responsible for the incident c. Make available data available for quality control analysis d. Document the incident on the patients chart 18. The nurse says. If you do not let me do this dressing change, I will not let you eat dinner with other residents in the dining room. This is an example of : a. Assault b. Battery c. Negligence d. Malpractice 19. An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, If you keep ringing, there will come a time I wont answer the bell.This is an example of: a. Slander b. Assault c. Battery d. Libel 20. A patient asks the nurse, What is a Living Will? the nurse should respond that it is a document that: a. Instructs a physician to withhold/withdraw life-sustaining procedures if death is near b. Enables a person to request medication to end life in a humane and dignified manner c. Gives consent to perform life-sustaining medical intervention during an emergency d. Wills ones organs to help others who need a transplant to sustain life Situation: As a nurse you must be responsible for the needs of your client. 21. Ms. R has been medicated for her surgery. The operating room (OR) nurse, when going through the clients chart, realizes that the consent form has not been signed. Which of the following is the best action for the nurse to take? a. Assume it is emergency surgery and the consent is implied b. Give the consent form and have the client sign it c. Tell the physician that the consent form is not signed d. Have a family member sign the consent form 22. Ms. R is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart. Which of the following is the best response for the nurse to take? a. Hand the cousin the clients chart to review b. Ask Ms. R to sign an authorization, and have someone review the chart with the cousin c. Call the attending physician and have the doctor speak with his cousin d. Tell the cousin that the request cannot be granted 23. Ms. R has had both wrists restrained because she is agitated and pulls out her IV lines. Which of the following would the nurse observe if Ms. R is not suffering any ill effects from the restraints? That: a. She has difficulty moving her fingers and making a fist b. Her skin is reddened where the limits were tied around her wrist c. Ms. Rs capillary refill is less than two seconds d. The client complains of numbness and tingling in her hand 24. The nurse is in the hospitals public cafeteria and hears two nursing assistants talking about Ms. R in 406. They are using her name and discussing intimate details about her illness. Which of the following actions is best for the nurse to take? a. Go over and tell the nursing assistants that their actions are inappropriate, especially in public place b. Wait and tell the assistants later that they were overheard discussing the client. Otherwise, they might be embarrassed. c. Tell the nursing assistants supervisor about the incident. It is the supervisors responsibility to address the issue

d. Say nothing. It is not the nurses job and she is not responsible for the assistants actions 25. A nurse comes up a motor vehicle accident when driving to work. The nurse administers care to the people involved. Under the Good Samaritan Act, the nurse could be liable: a. For nothing, any action is covered b. For gross negligence c. For not providing the standard care found in the hospital d. For not stopping and offering care 1. Answer D. Administering eye drops should be done in the lower conjunctival sac to ensure that the medication gets to eye. Option A is not done since some medications can irritate the cornea when placed directly in to it. Options B and C are not practiced because doing so cannot hold the medication into the eye. Its tendency would be, the medication would run out or flow out of the eyes. 2. Answer A. Infiltration happens when the intravenous fluid does not enter the veins, instead it is diffused in the areas outside the vein which explains why the area is swollen and cool to touch. Option B happens when there is there is an inflammation of the vein in the site. It is characterized by pain, swelling, redness and it is warm to touch. Option C is manifested by pain, swelling, warm to touch, redness and fever is present in the client. Option D is expected when the client complains of feeling pain in the IV site and that you can see in the IV tubing that it is filled with air. 3. Answer B. It is a priority nursing action to first assess the clients IV site before doing anything. Once there is a report of pain in the site, plus edema and erythema, we check for the patency of the IV site, if it is not patent, then we discontinue the IV and apply warm compress to the IV site to lessen swelling. Options A and D are incorrect because such actions will not relieve the client from pain, edema and erythema. Option C is not indicated because there is no accurate indication that there is a bacterial infection in the site. 4. Answer B. Quantity= desired dose/ available dose 0.125/ 0.25 = 0.5 tab. The nurse should dispense tablet of Digoxin. Options A, C and D are all incorrect answer. 5. Answer B. 41.66 or 42 gtts/min 6. Answer D. When a nurse is caring for quite a number of patients, to prevent the spread of infections among patients, she should know who are the possible carrier of infections and those who are at risk of acquiring one. Options A, B and C are inappropriate infection preventions that are indicated in this situation. 7. Answer A. Stool for ova and parasites does not require a sterile technique because we are after for the presence of ova and parasites. And if we are looking for the presence of bacteria in the stool, sterile technique is not still utilized because normally there will be a lot of bacteria in the stool. Options B, C and D require a sterile technique in order to identify what bacterial growth is present in the specimen. 8. Answer C. The patient is at greater risk of wound infection when he is punctured by a nail in the foot. He is at risk for acquiring tetanus infection once he is not given with tetanus toxoid immunization. The wound the nail creates is quite deep thus there is a great risk for infection. In the case of Option A, patients with colostomy is often given with antibiotics. Options B and D are incorrect because the wound created is not quite deep. 9. Answer C. The skin is the first line of defense of the body against the infections. In cases of burns more than 20% of the body, this defense is weakened thus the person is greatly predisposed to developing different kinds of infection. Burns does not only affect the ability of the skin to defend the body but it also alters the immunity of the body. Options A, B and D may predispose a patient from the development of infections but cannot be considered as great as compared to burns. 10. Answer C. Heat loss is achieved through different methods. Conduction happens when there is a direct contact of a material in the skin to achieve heat loss. In this case heat loss is achieved with the use of cooling blanket. Option A is achieved when body heat is diffused away from the body into the air via skin. Option B is achieved by moving air away from the body to replace the warmth the body has with the use of a fan. Option D is achieved with the use of water such as in tepid sponge baths. 11. Answer C. The stages of grief includes: Denial, Anger, Bargaining, Depression and Acceptance. The stage of denial is when the patient is unable to acknowledge the existence of the diagnosis. In this stage, the patient would seek more opinions from other doctors because she

cannot accept the fact of her diagnosis. Options A and D are an example of the stage anger, in which she asks a lot of questions regarding the reason of her sickness. Option D shows the acceptance of the patient. 12. Answer A. Touching to provide support is a form of therapeutic communication. The use of touch reinforces caring feelings. Option B is non therapeutic. Option C is incorrect because the nurse is not in the position to tell the patients family of her prognosis. It is only done by the patient or when the patient requests the nurse to do so. Option D may correct but is not the best answer indicated in this situation. 13. Answer C. Mrs. Estrada is undergoing the process of depression which is a normal in coping with the grief process. In order to be therapeutic for this patient, the nurse should accept this behavioural adaptation of the patient, since it is just normal. Options A, B and D are non therapeutic because this conditions do not allow the normal process of grieving. 14. Answer C. The patient is experiencing fear because she herself has seen how her father died in the same age as she has in the present. Options A, B and D may be correct but are not indicated in the situation presented. 15. Answer B. Bargaining is the stage when the patient tries new things in order for her to lengthen her life. She is willing to try therapies ranging from the conventional to non conventional methods of treating her cancer. Other options do not describe the grieving stage that Mrs. Estrada is experiencing. 16. Answer B. The Licensure of Registered Professional Nurses protects its main consumers which are the patients. Other options are not the reason as to why nurses undergo licensing. 17. Answer C. Incident reports are filled out in order to record details of unusual events occurring in the hospital and care of patients. In this case, the incident report is filled out in order to have an available data for quality control analysis and in the future when dealing with legal liabilities. Options A, B and D are incorrect because these are not the reason as to why nurses fill out incident reports. 18. Answer A. Assault is threatening or attempting to inflict injuries to the patient. The verbalization of the nurse clearly shows that it is a case of an assault. Option B is touching the patient without consent. This is done by pinching or slapping the patient. Options C and D are forms of violations that the nurse can commit to a patient in line with the patients profession. 19. Answer B. This is a case where the nurse committed an assault as manifested by the threatening behaviour of the nurse. Option A is achieved when you speak ill of a person. Option B is putting the threatening behaviour into action. Option D is committed when one talks ill of another through writing it in a published form. 20. Answer C. Living will is a legal document that an individual uses to make known his wishes to prolong his life. It is also known as advanced directives. In this case, a living will gives consent to perform life sustaining medical intervention to prolong life in cases of emergency. Other options presented are incorrect because they do not describe what a living will is all about. 21. Answer C. Consents allow the physician to do the medical procedures indicated for the patient. Prior to procedure, it is the doctors responsibility to obtain the patients consent and it is the responsibility of the nurse to let the patient sign the consent prior to the surgical procedure. Consent unsigned is like consent not given so it is a must that the nurse should tell the situation to the doctor performing the surgery. Options A, B and D are incorrect because they violate the legalities of the consent. 22. Answer B. The owner of the chart is the patient himself so it is a must that before authorizing any individual to view the chart, authorization should secured and have someone review the chart with the patients physician cousin. Options A, C and D are the incorrect way of dealing such situations involving the patients chart. 23. Answer C. When restraints are applied, it is a must for the nurse to assess the quality of the patients skin where the restraint is applied. The priority assessment should be done by assessing the patients capillary refill so as to ensure circulation of the extremity. Capillary refill of less than two seconds shows that there is a good circulation in that area. Options A, B and D are signs that the restraints applied are having negative effects to the patients extremity. 24. Answer A. It is the preferred answer because right there in then you will be able to stop the discussion of the patients case in front of a lot of people. Option B may be correct because you are saving from humiliation the nursing assistance but it is not the preferred answer because doing so

will allow further discussion of the case and more harm will be committed. Option C may be correct because in the first place you are not their immediate superior but not appropriate in this situation because it will further the discussion of the case thus allowing a lot of people to overhear it. Option D is the worst thing to do since you will not do anything to prevent it from happening. 25. Answer A.Good Samaritan Act protects those who choose to lend a hand during emergency situations. In this act, the nurse is not liable to any laws once she helps an injured individual during this emergency. Options B, C and D are incorrect because these do not explain what the act is all about.