QE: P2

Question 1

When assessing a client’s peripheral pulse, the health care provider is also assessing which of the following?

a. Depth
b. Rhythm
c. Sound
d. Stress

Answer 1

a. Depth

Question 2

A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first?

a. Administering diuretic medication.
b. Obtaining an order for a Foley catheter.
c. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient’s progress.
d. Utilizing the power of suggestion by turning on the faucet and letting the water run.

Answer 2

d. Utilizing the power of suggestion by turning on the faucet and letting the water run.

Question 3

While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the client’s bed linens. How can
the nurse avoid this situation with the patch now being applied?
a. Run a finger around the adhesive edges of the new patch before placing it on the client’s skin.
b. Shave the area where the patch is being applied.
c. Press firmly over the patch with the palm of the hand for about 10 seconds after applying it to the skin.
d. Place a heating pad over the area where the patch is applied for 10 minutes after application.

Answer 3

b. Shave the area where the patch is being applied.

Question 4

Techniques that would be useful in eliciting information about how this patient coping with her diagnosis include:

a. Asking closed questions
b. Soliciting information from the patient’s family before interviewing the patient
c. Soliciting information from the patient’s family after interviewing the patient
d. Asking open-ended questions

Answer 4

d. Asking open-ended questions

Question 5

A research methodology that systematically collect the data, statistically analyze and numerically interpret the data:

a. Quantitative research
b. Experimental research
c. Qualitative research
d. Non-experimental research

Answer 5

a. Quantitative research

Question 6

Past health history taking focuses on?

a. Previous hospitalizations, childhood diseases, and surgeries
b. Client’s health strengths and weaknesses
c. Reason for seeking health care
d. Familial diseases

Answer 6

a. Previous hospitalizations, childhood diseases, and surgeries

Question 7

The nurse needs to remove personal protective equipment after performing the procedure to a client. What is the chronological order the
nurse should perform?

a. Remove the gloves, gown, face shield, face mask
b. Remove the gown, face shield, face mask, gloves
c. Remove the gloves, face shield, face mask, gown
d. Remove the gown, gloves, face shield, face mask

Answer 7

c. Remove the gloves, face shield, face mask, gown

Question 8

A prevention that focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications or
worsening conditions in which activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient
to return to a normal level of health as early as possible

a. Primary prevention
b. Secondary prevention
c. Disability Limitations
d. Tertiary prevention

Answer 8

d. Tertiary prevention

Question 9

Stereotyping is defined as

a. A worldview that each of us forms values and beliefs based on our own culture
b. The belief that one’s cultural values are superior to all others
c. Expecting all members of a cultural group to hold the same beliefs and behave in the same way.
d. A culture-bound syndrome found in many cultural groups

Answer 9

c. Expecting all members of a cultural group to hold the same beliefs and behave in the same way.

Question 10

Patient A had fever. He inquired of the normal body temperature. What would the nurse’s best answer be? A) 35-37 degrees Celsius

a. 40-42 degrees Celsius
b. 38-39.5 degrees Celsius
c. 36-37.5 degrees Celsius

Answer 10

c. 36-37.5 degrees Celsius

Question 11

Which of the following statements best describe arteries?

a. all arteries contain valves to prevent the back-flow of blood
b. only large arteries are lined with endothelium
c. all arteries carry oxygenated blood towards the heart
d. all arteries carry blood away from the heart

Answer 11

d. all arteries carry blood away from the heart

Question 12

Life co-exist with the nursing profession where worth and dignity of others have to be given high value. It is then expected that nurses do what
is considered right regardless of the personal cost. Nurses must show:

a. Loyalty
b. Prudence
c. Integrity
d. Competence

Answer 12

c. Integrity

Question 13

A nurse is to start an intravenous infusion to a 5-year-old. Which of the following is the most appropriate size of over the needle catheter for the patient?

a. 22- to 24-
b. 23- to 25-
c. 14- to 16-
d. 18- to 20-

Answer 13

a. 22- to 24-

Question 14

Mr. Cruz informs you that he has patchy loss of skin color on his hands, face and lips. This indicates that he has:

a. Acanthosis Nigricans
b. Vitiligo
c. Butterfly rash
d. Albinism

Answer 14

b. Vitiligo

Question 15

Miss Jhanine is lying flat on abdomen in bed. Which of the following is NOT a Problem to be Prevented in this Position?

a. Hyperextension of the spine
b. Internal rotation of the femur
c. Facilitates breathing
d. Hyperextension of the knees

Answer 15

d. Hyperextension of the knees

Question 16

At the end of palpation technique a client suspected to have cholecystitis (inflamed gallbladder), the nurse presses her fingertip just below the
right costal margin. The nurse is initiating which test?

a. Blumberg’s sign
b. Psoas sign
c. Murphy’s sign
d. Obturator sign

Answer 16

c. Murphy’s sign

Question 17

The prescriber orders for Catapress (Clonidine) 25mg to be given orally once a day to control a patient’s high blood pressure. The nurse takes
the patient’s vital signs and finds that the blood pressure is 120/80 and the heart rate is 60 beats per minute. What does the nurse do first
before giving this medication?

a. Call for your supervisor for help
b. Check the order for prescriber limitations on when the drug should be given
c. Notify the prescriber and ask if the medication should be given
d. Give the medication to the relative of the patient and let him administer the drug to the patient

Answer 17

b. Check the order for prescriber limitations on when the drug should be given

Question 18

Refers to an imaginary vertical line drawn through the body’s center of gravity.

a. Base of support
b. Line of gravity
c. Center of gravity
d. None of the above

Answer 18

b. Line of gravity

Question 19

The nurse needs to apply personal protective equipment before entering a client’s room. What is the chronological order the nurse should
perform?

a. Apply face mask, face shield, gown, gloves
b. Apply gloves, face shield, gown, face mask
c. Apply the gown, gloves, face mask, face shield
d. Apply the gown, face mask, face shield, gloves

Answer 19

d. Apply the gown, face mask, face shield, gloves

Question 20

A flat sound during percussion is appreciated over the

a. Bones
b. Abdomen
c. Lungs
d. Liver

Answer 20

a. Bones

Question 21

This lung sound is mostly heard all over lung fields:

a. Bronchial sound
b. Vesicular sound
c. Tracheal sound
d. Bronchovesicular sound

Answer 21

a. Bronchial sound

Question 22

The following are the list of criteria used to evaluate the bedmaking skills EXCEPT:

a. Correct placement of sheets with regards to seam.
b. Patient undisrupted sleep
c. Comfort of the patient
d. Wrinkle free

Answer 22

b. Patient undisrupted sleep

Question 23

Upon inspection the nurse noticed that the client is uncircumcised. The nurse recalls that he has to include the following techniques in his assessment except:

a. Retracting the foreskin
b. Inspecting the location of the meatus
c. Palpating and illuminating the scrotum
d. Inspecting the shaft, foreskin, and glans

Answer 23

c. Palpating and illuminating the scrotum

Question 24

Taste sensation of the posterior 1/3 of the tongue is made possible by?

a. Spinal Accessory
b. Glossopharyngeal
c. Trigeminal
d. Facial

Answer 24

b. Glossopharyngeal

Question 25

The nurse would assess the first heart sound in different precordial landmarks. To auscultate the mitral area or the point of maximal impulse (PMI), one's stethoscope should be placed on the: a. 5th ICs, mid-clavicular line b. 2nd ICS, left sternal boarder c. 2nd ICS, right sternal boarder d. 4th ICS left sternal border

Answer 25

a. 5th ICs, mid-clavicular line

Question 26

Maintaining confidentiality of patient information is part of nurse's: a. Managerial and leadership functions b. Ethical and legal obligations c. Advocacy role d. Role as a counselor

Answer 26

b. Ethical and legal obligations

Question 27

A condition which is the result of a cardiopulmonary problem that makes the skin appear blue-tinged is called: a. Cyanosis b. Pallor c. Jaundice d. Carotenemia

Answer 27

a. Cyanosis

Question 28

Which of the following is most significant when assessing headache or neck pain a. Severity b. Associated symptom c. Activity d. Position of comfort

Answer 28

a. Severity

Question 29

A nurse is caring for a client who is receiving intravenous piggyback medication intermittently via a primary intravenous infusion line. Which nursing intervention is most important to prevent infection associated with this therapy? a. Set the alarm on the electronic infusion device to alert the nurse is the tubing becomes obstructed. b. Prime the tubing of an intravenous piggyback until a drop of solution appears at the distal end of the tubing. c. Wear sterile gloves when preparing and administering parenteral solutions. d. Wipe the port on the primary intravenous set with an alcohol sponge before connecting the intravenous piggyback.

Answer 29

d. Wipe the port on the primary intravenous set with an alcohol sponge before connecting the intravenous piggyback.

Question 30

The most common problem areas for nurses are the failure to properly document the care provided. The main rule of thumb is: a. 'If it is not in the policy, it will not be covered by the employer' b. 'If it is not reported properly, it is not legal' c. 'If it is not appropriate for the patient, it should not be given' d. 'If it is not documented, it is not done'

Answer 30

d. 'If it is not documented, it is not done'

Question 31

Mrs. Castro,a 35-year-old businesswoman is scheduled for gynecologic annual checkup. You should instruct her the following except: a. All are incorrect b. Not to have sex within 24 hours before the examination c. Have the exam when she is not menstruating d. Use vaginal cream instead of regular soap when cleaning her genitalia

Answer 31

d. Use vaginal cream instead of regular soap when cleaning her genitalia

Question 32

During adolescence, concerns related to ______ are of paramount concern. a. Body image b. Identity c. Self-concept d. Self-esteem

Answer 32

a. Body image

Question 33

A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? a. Cleanse the meatus 3 times with the same cotton ball from clean to dirty. b. Hold the shaft of the penis with the dominant hand. c. Cleanse the meatus with circular strokes beginning at the meatus and working outward. d. Hold the shaft of the penis at a 60-degree angle.

Answer 33

c. Cleanse the meatus with circular strokes beginning at the meatus and working outward.

Question 34

``` A physician's order reads clindamycin phosphate 0.3g in 50 ml PNSS to be administered IV over 30 minutes. The medication label reads clindamycin phosphate (Cleocin Phosphate) 900 mg in 6 ml. A nurse prepares how many ml of the medication to administer the correct dose. ``` a. 2mL b. 5 mL c. 3 mL a. d 1mL

Answer 34

a. 2mL

Question 35

A nurse is caring for a client that is healing from an achilles tendon surgery. The nurse is practicing active range of motion with the client and notes the patient is still unable to point their toes down to the floor. The nurse should chart this as a lack of which of the following movements? a. Dorsiflexion b. Plantar Flexion c. Supination d. Pronation

Answer 35

b. Plantar Flexion

Question 36

When a female client asked a nurse about the relationship of ovulation and body temperature, the nurse knows that: a. Body temperature falls a bit then suddenly rises upon ovulation b. Body temperature decreases upon ovulation c. Body temperature is not affected by hormonal changes d. Body temperature increases a bit then suddenly falls upon ovulation

Answer 36

b. Body temperature decreases upon ovulation

Question 37

Nurse advocates often are conflicted about respecting a patient's right to be self-determining, while at the same time wanting to do everything in their power to promote the patient's best interests. Which is the best general guideline for situations like these? a. Nurse rules! "It may be your life but in this instance you don't know enough to make the right choice!" b. Patient rules! "It's my life!" c. Treat the patient fairly, try to give the patient his or her due. d. When in conflict, weight the benefits and risks of each option and choose wisely

Answer 37

d. When in conflict, weight the benefits and risks of each option and choose wisely

Question 38

A client with a history of sinusitis is complaining of heaviness and pain below the eye orbits and within the cheeks, the nurse may validate the information to suspect sinusitis by palpating which sinus region: a. Ethmoid b. Maxillary c. Frontal d. Sphenoid

Answer 38

b. Maxillary

Question 39

Cracking felt and heard upon joint movement is called a. Crepitus b. Calcifications c. Fremitus d. Subcutaneous emphysema of the joints

Answer 39

a. Crepitus

Question 40

When palpating for lymph nodes, the following characteristic can be use as normal findings. EXCEPT: a. Non-tender b. Immobile c. Discrete delineation d. Soft

Answer 40

b. Immobile

Question 41

Which of the following are examples of a macule? a. Freckles, wheal, petechiae b. Freckles, petechiae, flat moles c. Freckles, nodule, wheal d. Freckles, vesicle, bulla

Answer 41

b. Freckles, petechiae, flat moles

Question 42

Your patient requires 1000ml of PNSS at 125 ml/hour. What's the infusion time? If the normal saline is hung at 8AM, what time will the infusion end? a. 5:00 PM b. 4:00 PM c. 6:00 PM d. 8:00 PM

Answer 42

b. 4:00 PM

Question 43

A 25 year-old female was brought to the clinic due to diarrhea. The client complains of cramping pain and feeling of being gassy. During the interview which question should the nurse ask to confirm the change in frequency of bowel movement: a. When did your diarrhea start? b. What triggers your bouts of diarrhea? c. What is the consistency of your stool? d. What is vour usual bowel pattern?

Answer 43

d. What is vour usual bowel pattern?

Question 44

After being medicated for anxiety a client who has congestive heart failure says to the nurse, "I guess you are too busy to stay with me." The best response in this circumstance is: a. "I have to go now, but I will come back in 10 minutes b. "You will feel better; I will adjust your oxygen mask." c. "I have to see other clients. d. "The medication will help you rest soon."

Answer 44

a. "I have to go now, but I will come back in 10 minutes

Question 45

Because the patient's Bed becomes the most important element in client's life, when assessing the patient's bed, the nurse should check for the following a. Noise, Safety, Cleanliness b. Cleanliness, Call Light, Ventilation c. Safety, Cleanliness, Comfort, d. Comfort, Siderails, Fresh Air

Answer 45

c. Safety, Cleanliness, Comfort,

Question 46

The type of linen that the nurse prepares and placed the opening away from the door to prevent entrance of microorganism inside the case. a. Top Sheet b. Rubber Sheet c. Pillow Case d. Draw Sheet

Answer 46

c. Pillow Case

Question 47

A client's status is deteriorating, and the physician prescribes a medication to be administered immediately one time. The nurse would contact the pharmacy and identify this medication order as being of which type? a. Standing b. PRN c. Single order d. STAT

Answer 47

d. STAT

Question 48

The client has an impairment of the cranial nerve I. Specific to this impairment the nurse will plan to do which of the following to ensure client safety? a. Test the temperature of the shower water. b. Check the temperature of the food on the dietary tray. c. Provide a clear path for ambulation without obstacles. d. Speak loudly to the client

Answer 48

c. Provide a clear path for ambulation without obstacles.

Question 49

This serves as the foundation of the standards of nursing practice developed by the American Nurses Association (ANA): a. a Nursing process b. Note on Nursing c. Standards of Practice d. Theoretical Models

Answer 49

a. a Nursing process

Question 50

The principles of medical asepsis are as follows, EXCEPT: a. Microorganisms are transferred by gravity when one is held above another. b. Microorganisms move through space on air current c. Microorganisms are transferred from one surface to another whenever objects touch. d. Microorganisms move very quickly on dry surfaces but move slowly through moisture.

Answer 50

d. Microorganisms move very quickly on dry surfaces but move slowly through moisture.

Question 51

The nursing education curricula have been revised to fit the changing needs of the society, with its current emphasis on: a. Decision making b. Enhancing quality nursing education c. Provision of care d. Critical thinking

Answer 51

b. Enhancing quality nursing education

Question 52

The tail of a woman's breast tissue occasionally extends: a. Into the Angle of Louis b. Across the sternum c. Into the Axilla d. Spinal process

Answer 52

c. Into the Axilla

Question 53

A 40 year old, male client is bought to Emergency Room with chief complaint of chest pain. The attending nurse used COLDSPA pneumonic during the interview Which if the subjective data collected belong to the "Associated Factors" a. It hurts in the middle of my chest b. The pain lasted for 20 minutes and that was scary c. I felt left arm discomfort, sweaty, and sick to my stomach d. The pressure-like pain started after exercise

Answer 53

c. I felt left arm discomfort, sweaty, and sick to my stomach

Question 54

After three years of working as a staff nurse in the medical ward, Miss Fernando was promoted as a head nurse of a new unit on the basis of the leadership skills she had demonstrated with her co-nurses. As a good leader, Miss Fernando has most likely demonstrated that she can: a. Expect pressure upon her co-workers to work to achieve objectives b. Be subservient to nursing authorities in the hospital c. Influence her co-workers to work for the achievement of the goals of nursing service d. Always follow instructions and mandated of the hospital administration

Answer 54

c. Influence her co-workers to work for the achievement of the goals of nursing service

Question 55

All, EXCEPT ONE, are the Parts of the Triangular Bandage: a. Ends b. Base and Body c. None of the above d. Apex or point

Answer 55

c. None of the above

Question 56

Nursing health assessment includes: a. Collection of data, validation of data, documentation of data b. Collection of data, develop diagnosis, prioritize identified problems c. Collection of data, analyzing data, developing diagnosis evaluating gathered data d. Collection of data, developing a plan, evaluating the effectiveness of Intervention

Answer 56

a. Collection of data, validation of data, documentation of data

Question 57

Preparing a patient for anus and rectum examination includes the following except: a. Ensuring that the examination room is at a comfortable temperature, has adequate lighting, and free from interruptions b. Instruct patient not to void prior to the examination c. Instructing the patient to remove pants and underwear and cover up with drape sheet d. Donning gloves e. Identifying the patient and explaining the procedure

Answer 57

b. Instruct patient not to void prior to the examination

Question 58

Shared practices and rituals used to express one's faith can be called a. Denomination b. Religion c. Philosophy d. Spirituality

Answer 58

b. Religion

Question 59

``` A client shared to the nurse that she can't pass her driving class because she has difficulty seeing from a distance. The nurse should understand that this is a sign of: ``` a. Hyperopia b. Miosis c. Scotoma d. Myopia

Answer 59

d. Myopia

Question 60

Orientation to spheres is part neurologic assessment. The "spheres" include the following except: a. Abstract Thinking b. Time c. Person d. Place

Answer 60

a. Abstract Thinking

Question 61

As you inspect your male client's anterior part of the body, you notice an accessory nipple. You know that this is also called: a. Supernumerary nipple b. Cystic nipple c. Fibrocystic nipple d. Intraductal nipple

Answer 61

a. Supernumerary nipple

Question 62

Movement the bones of the forearm so that the palm of the hand faces downward when held in front of the body is called: a. Internal Rotation b. External Rotation c. Supination d. Pronation

Answer 62

d. Pronation

Question 63

In utilizing the nursing process, nurses should remember that assessment phase is: a. linear b. Completed in admission c. performed only by nurses d. Continuous

Answer 63

d. Continuous

Question 64

Failure to follow the manufacturer's recommendations for operating the equipment belongs to what category of negligence? a. Failure to assess and monitor b. Failure to follow standards of care c. Failure to use equipment in a responsible manner d. Failure to document

Answer 64

c. Failure to use equipment in a responsible manner

Question 65

The main purpose of documentation is: a. To ensure that nurses would know what is happening to the client. b. To promote effective communication among multidisciplinary health team members c. To establish an initial data base d. For nurses to address the client's specific health needs

Answer 65

d. For nurses to address the client's specific health needs

Question 66

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? a. Increased energy levels b. Elevated blood pressure c. Decreased skin turgor d. Distended abdomen

Answer 66

c. Decreased skin turgor

Question 67

The following are significant subjective data findings in musculoskeletal assessments except a. Exercise patterns b. Laterality and symmetry c. Joint stiffness d. Pain

Answer 67

d. Pain

Question 68

While preparing to administer an eye ointment, the nurse inadvertently squeezes the tube, discarding the first bead of medication. What action should the nurse take at this point? a. Notify the pharmacy and request a new, unopened tube of ointment. b. Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway. c. Have a second licensed nurse witness the waste and sign the chart. d. Continue to squeeze the tube until a clear line of ointment has been discarded from the tip

Answer 68

b. Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway.

Question 69

The following has to be noted when assessing the nasal cavity EXCEPT for: a. Obstructions b. Deviations c. Lesions d. Inflammation

Answer 69

c. Lesions

Question 70

The plan in the problem -solving process is equivalent to which step in the research process? a. Implementation b. Design c. Goal identification d. Outcomes

Answer 70

b. Design

Question 71

_________ effectively with clients of various ethnic and cultural backgrounds are critical to providing culturally competent nursing care. a. Health educating b. Interacting c. Demonstrating d. Communicating

Answer 71

d. Communicating

Question 72

The type of linen that the nurse prepares and placed over the draw sheet to keep the patient warm and maintain patient's privacy. a. A Draw Sheet b. Rubber Sheet c. Bottom Sheet d. Top Sheet

Answer 72

d. Top Sheet

Question 73

Two-year-old Jason's mother states, "Jason vomited 8 ounces of his formula this morning." This statement is an example of: a. Subjective data from a secondary source b. Obiective data from a secondarv source c. Subiective data from a primary source d. Obiective data from primary source

Answer 73

b. Obiective data from a secondarv source

Question 74

Prior to auscultation the nurse recalls that disease process behind diarrhea is an increase in peristaltic movement or peristaltic wave. The nurse may EXPECT which bowel sound variance: a. Normoactive b. Hypoactive c. Hyperactive d. Cramping

Answer 74

c. Hyperactive

Question 75

Johnny is a 5-year-old boy who comes to the clinic for his scheduled injections. Which physical indications would lead you to suspect child abuse? a. Bruising on the upper portion of his buttocks b. Crying when he sees the needle for the injection c. Irregular pattern of small, circular reddened areas with healing blisters on various parts of his body d. Regular pattern of circular, coin-sized reddened areas on his back

Answer 75

a. Bruising on the upper portion of his buttocks

Question 76

Mrs. C delivered her first baby 2 days ago. The nurse assigned to her instructed her the benefits of breastfeeding. The nurse determines that she needs further instructions when she says that: a. Breastfeeding is associated with a reduced risk of child infections b. Breastfeeding promotes healthy weight gain c. She plans to breast fed her baby for 6 months to one year d. She is afraid that she cannot produce sufficient breast milk because her breasts are small

Answer 76

d. She is afraid that she cannot produce sufficient breast milk because her breasts are small

Question 77

In your assessment of the client with COPD, you noticed an equalization of the thoracic width on posterior and lateral view. The nurse recall that this thoracic deformity as? a. Kyphoscoliosis b. Pectus Excavatum c. Pectus Carinatum d. Barrel Chest

Answer 77

d. Barrel Chest

Question 78

In performing Rinne test a normal finding would mean? a. Air conduction is shorter than Bone conduction b. Air conduction is longer than Bone conduction c. Air conduction is softer than Bone conduction d. Air conduction is louder than Bone conduction

Answer 78

b. Air conduction is longer than Bone conduction

Question 79

Part of history of present health concern in neurologic assessment a. Diet b. Family history c. Numbness and tingling d. None of the above

Answer 79

c. Numbness and tingling

Question 80

The primary function of the musculoskeletal system is which of the following a. Protection of the fragile body organs b. Erythropoesis through the spongy bones c. Protein source from the muscular tissue d. Provides structure and facilitates movement

Answer 80

d. Provides structure and facilitates movement

Question 81

Testicular self-examination is best done when? a. After a workout b. Two weeks after ovulation c. After a warm shower in front of a mirror d. During a warm tub bath

Answer 81

c. After a warm shower in front of a mirror

Question 82

All EXCEPT ONE, are the four (4) Basic Elements of Body Mechanics: a. Body alignment (Posture) b. Coordinated movement c. Balance d. None of the above

Answer 82

d. None of the above

Question 83

In initiating palpation of the anus of a male patient, the nurse recalls that the best approach is: a. Placing gloved, lubricated finger by the anal orifice and instructing the patient to bear down while gently inserting it into the anal sphincter, with the tip of the finger toward the anterior rectal wall b. Pushing the tip of lubricated, gloved index finger in the anal orifice c. Spreading the buttocks and waiting for anal opening as the patient is instructed to bear down. Upon opening approach the anal sphincter with the tip of a gloved, well-lubricated finger. d. Place one hand on the patient's suprapubic area, while the other hand's gloved and lubricated index and middle fingers approach the anal sphincter and vaginal canal.

Answer 83

a. Placing gloved, lubricated finger by the anal orifice and instructing the patient to bear down while gently inserting it into the anal sphincter, with the tip of the finger toward the anterior rectal wall

Question 84

Which of the following is considered as primary source of information when gathering subjective data? a. The client b. Client's previous medical record c. Client's family d. The client's friends

Answer 84

a. The client

Question 85

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do? a. Remove the catheter, wipe with alcohol, and reinsert after lubrication. b. Fill the balloon with the recommended sterile water. c. Throw the catheter way and begin again. d. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

Answer 85

c. Throw the catheter way and begin again.

Question 86

The type of linen that the nurse prepares for bedmaking to help lift or move a patient and to protect the bottom sheet from soiling. a. Bottom Sheet b. Rubber Sheet c. Top Sheet d. A Draw Sheet

Answer 86

b. Rubber Sheet

Question 87

A primary health care provider orders 1,000 mL 0.9% sodium chloride to be infused over 6 hours. The administration set states that the drop factor is 15 drops per mL. At which rate should the nurse set the IV flowrate? a. 250 drops per minute b. 60 drops per minute c. 42 drops per minute d. 166 drops per minute

Answer 87

c. 42 drops per minute

Question 88

The nurse is planning to administer medications to a new client. What is the nurse's greatest priority in administering these medications? a. Before giving the medications, know what the intended effects are for this client. b. Assess the client's knowledge of the action of the medications. c. Be certain the medications are given within 15 minutes of the time they are scheduled. d. Document the administration accurately so the reimbursement is correct.

Answer 88

a. Before giving the medications, know what the intended effects are for this client.

Question 89

All, EXCEPT ONE, are the reminders in Gloving: a. Place package on a clean, dry surface b. Always wash your hands after removing gloves because the gloves may have imperfections which could allow entry of microorganisms c. Clean to clean, dirty to dirty d. None of the above

Answer 89

d. None of the above

Question 90

A physical examination technique that helps the nurse detect the density of an underlying structure: a. Auscultation b. Inspection c. Palpation d. Percussion

Answer 90

c. Palpation

Question 91

During palpation the client displayed ticklishness. What nursing consideration should the nurse observe to minimize it? a. Warm the hand before palpation. b. Asking the client to look away and think of relaxing thoughts during palpation. c. Use distraction such as pinching the client's arm before palpation. d. Allow self-palpation with the nurse's hand on client's hand then gently slide the nurse's hand from the client's hand to her abdomen.

Answer 91

d. Allow self-palpation with the nurse's hand on client's hand then gently slide the nurse's hand from the client's hand to her abdomen.

Question 92

Accurate and __________ documentation is also a critical component of legal protection for the nurse. a. Concise b. Complete c. Clear d. Ambiguous

Answer 92

b. Complete

Question 93

A prevention that occurs when a defect or disability is permanent and irreversible in which interventions are directed at preventing complications and deterioration. a. Secondary prevention b. Restoration c. Tertiary prevention d. Primary prevention

Answer 93

c. Tertiary prevention

Question 94

Pain that is felt in a part of a body that has been removed is called: a. Phantom pain b. Neuropathic pain c. Radiating pain d. Referred pain

Answer 94

a. Phantom pain

Question 95

The second heart sound, "dub", is valuable aid in assessing which valve? a. Semilunar valves b. Atrioventricular valve c. Ascending aortic wall d. Pulmonary artery wall

Answer 95

a. Semilunar valves

Question 96

During percussion the nurse noted tympanic tone generally over the abdomen.This could mean: a. Abnormal b. Unremarkable c. Nothing unusual d. Distended bladder

Answer 96

c. Nothing unusual

Question 97

To maintain the sterile field, remember these Principles, EXCEPT: a. A Sterile object remains sterile only if objects that touch it are also sterile. b. If your hands or a sterile object drop below waist level, both are considered not contaminated. c. A sterile object becomes contaminated when touched by any non-sterile object. d. A sterile field becomes contaminated if moisture permeates the field

Answer 97

b. If your hands or a sterile object drop below waist level, both are considered not contaminated.

Question 98

A diagram used by nurses to illustrate the family history of the client: a. Polygram b. Genogram c. Histogram d. Cardiogram

Answer 98

b. Genogram

Question 99

A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Fully inflating the catheter's balloon according to the manufacturer's recommendation c. Disconnecting and replacing the catheter drainage bag once per shift d. Maintaining a closed urinary drainage system

Answer 99

a. Inserting the catheter using strict clean technique

Question 100

The nurse informed patient A that the following are the sites for measuring body temperature: A) Oral and rectal a. All of the above b. Axillary and Tympanic membrane c. Rectal and Axillary

Answer 100

c. Rectal and Axillary