RUEL M. BERSABE’S 1.

A footboard
OUR LADY OF PERPETUAL HELP REVIEW CENTER 2. A trochanter roll
CHED Accreditation No. 73 3. A turning sheet
4. A foam mattress
FUNDAMENTALS OF NURSING A 10. The nursing explanation that best describes the primary
New Updates – December 2010 purpose of the CPM machine is that it is used to.
1. Strengthen leg muscle
1. While providing nursing care for the client in Buck’s 2. relieve foot swelling
traction, which assessment finding indicates a need for 3. Reduce surgical pain.
immediate action? 4. Restore joint function.
1. The traction weights are hanging above the 11. If the physician orders the following laboratory tests to
floor. determine gout, the elevation of which test validates the
2. The leg is in line with the pull of the traction. client’s diagnosis?
3. The client’s foot is touching the end of the 1. Creatinine clearance
bed. 2. Blood urea nitrogen
4. The rope is in the groove of the traction 3. Serum uric acid
pulley. 4. Serum calcium
2. The nurse enters the client’s room to assess the traction 12. The client with gout experiences an acute attack. Which
apparatus. Which of the following interferes with the piece of equipment is best for promoting his comfort?
effectiveness of the Russell’s traction? 1. A bed cradle
1. The rope is strung tautly from pulley to pulley. 2. An electric fan
2. The trapeze is hanging above the client’s 3. A foam mattress
chest. 4. A fracture bedpan
3. The rope is knotted at the location of a pulley. The physician orders transcutaneous electric nerve stimulation
4. The weight is hanging about 24 inches from (TENS) in the location of the discomfort on the arm opposite the
the floor. amputation.
3. If the client is allergic to penicillin, it is essential that the 13. When the client asks the nurse how the TENS unit works,
nurse question the medical order prior to giving which you respond that one of the most widely held theories is
type of antibiotic? that sensation created by the TENS machine.
1. Aminoglycosides like gentamicin sulfate 1. Blocks the brain’s perception of pain impulses.
(Garamycin) 2. Travels to the nerve root amputated arm.
2. Cephalosporins like cefaclor (Ceclor) 3. Destroys the brain’s pain center.
3. Tetracyclines like doxycyline (Vibramycin) 4. Weakens the arm’s sensory nerves.
4. Sulfonamides like trimethoprim- A myelogram with a water-soluble contrast dye is ordered to
sulfamethoxazole (Bactrim) confirm the diagnosis of a herniated intervertebral disk.
4. Which laboratory test, if elevated, is most diagnostic for 14. After the client returns from the myelogram. It is most
rheumatoid arthritis? appropriate for the nurse to keep the client quiet and to.
1. Erythrocyte sedimentation rate (ESR) 1. Reduce glare from bright lights.
2. Partial thromboplastin time (PTT) 2. Withhold food and fluids for 12 hours.
3. Fasting blood sugar (FBS) 3. Administer sedatives every 6 hour.
4. Blood urea nitrogen (BUN) 4. Encourage a high fluid intake.

A cervical halter type of skin traction is applied to a client who The physician plans to do a lumbar puncture (spinal tap) on the
has experienced a whiplash injury in a motor vehicle accident. client who may have meningitis.
5. When the nurse makes rounds at the beginning of the 15. To facilitate performing the lumbar puncture, it is best for
shift, which observation requires immediate attention? the nurse to place the client.
1. The halter rest under the client’s chin and 1. In a knee-chest (genupectoral) position
occiput. 2. Sitting up in an orthopnic position
2. The client’s ears are clear of the traction 3. In a side-lying position with his neck flexed.
ropes. 4. In a left lateral position with right knee flexed.
3. The weight hangs between the headboard and 16. While awaiting the results of diagnostic tests best to care
wall. for the client with possible meningitis.
4. There is a soft pillow beneath the client’s 1. Droplet precaution.
head. 2. Airborne precautions.
6. Which statement made by the client indicates that further 3. Contact precautions
instruction regarding corticosteroid therapy is necessary? 4. Standard precautions
1. “I am susceptible to getting infections.”
2. ‘I should never stop taking my medication A 23 year-old woman who experienced a generalized seizure
abruptly.” while at work is undergoing diagnostic tests.
3. “I may become very depressed and perhaps 17. When preparing a client for an electroencephalogram
suicidal.” (EEG), which nursing action is appropriate to perform?
4. ‘I may develop low blood sugar and need 1. Administer a pretest sedative an hour before.
glucose.” 2. Withhold food and water after midnight.
3. Assist the client with shampooing her hair.
Before the total hip replacement, the nurse teaches the client 4. Take client’s blood pressure lying and sitting.
how to use an incentive spirometer. 18. When implementing this order, which nursing action is
7. Which client statement indicates that he has a correct most appropriate?
understanding of its use? 1. the client is moved to a room close to the
1. “I should position the mouthpiece and inhale nursing station.
deeply.” 2. The client’s food is served in paper and plastic
2. ‘I should position the mouthpiece and exhale containers.
forcefully.” 3. The overhead light is left on at all times.
3. “I should position the mouthpiece and cough 4. The side rails on the bed are softly padded.
effectively.” 19. When the client who has had an EEG begins to have a
4. “I should position the mouthpiece and breathe seizure, which action should the nurse take first?
naturally.” 1. Administer oxygen by nasal cannula.
8. After the client undergoes a total hip replacement, how 2. Take her blood pressure and pulse.
should the nurse position the affected hip? 3. Restrain her arms and upper body.
1. Adduction 4. Place her in a side-lying position.
2. Abduction
3. Flexion The medical record of a client with epilepsy indicates that he
4. Extension has had two previous episodes of status epilepticus.
9. Which item is best for preventing external rotation of the
operative leg when caring for the client with the total hip 20. Which emergency drug should the nurse plan to have
replacement? available in case the client has a similar episode?

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 1. Diazepam (Valium) 1. Shorter and straighter.
2. Phenytoin (Dilantin) 2. Longer and straighter.
3. Carbamazepine (tegretol) 3. Shorter and more curved.
4. Phenobarbital sodium (Luminal) 4. Longer and more curved.

A computed tomography scan (CT) of the brain with contrast The client with possible Meniere’s disease will undergo a caloric
dye is ordered on the unconscious client. test.
21. If the client’s wife reports that the client has allergies,
which one must be reported to the physician before the 30. The teaching plan for preparing the client for this
CT? diagnostic test includes the explanation that.
1. Tomatoes 1. Cold water and warm water are instilled in
2. Shellfish each ear.
3. Chocolate 2. Earphones are worn through which sounds are
4. Strawberries transmitted.
A client with symptoms that suggest a brain tumor is scheduled 3. Scalp electrodes are attached to the head in a
for positron tomography (PET). darkened room.
22. When the nurse provides test preparation instructions, 4. Blood is drawn from a vein and examined
which substance is it important for the client to avoid the microscopically.
day before the rest? A nursing assistant with an allergy to latex asks the nurse
1. Caffeine advice on carrying out standard precautions for preventing
2. Food dyes transmission of blood-borne viruses.
3. Diuretics
4. Antibiotics 31. The best advice the nurse give is to.
1. Rinse the latex gloves with running tap before
23. Before the client is discharged following the PET, which donning them.
instruction is most appropriate? 2. Apply a petroleum ointment to both hands
1. Take a mild laxative tonight. before donning latex gloves.
2. Increase your fluid intake. 3. Eliminate wearing gloves, but wash both
3. Get at least 8 hours of sleep. hands vigorously with alcohol afterward.
4. Report any abdominal discomfort. 4. Wear two pairs of vinyl gloves when there
potential for contract with blood.
The client who underwent a craniotomy returns to the nursing The client with diabetes insipidus is treated with intranasal
unit after 6 hours of surgery. lypressin (Diapid), 2 sprays q.i.d. and as needed.

24. During the immediate postoperative assessment when 32. The nurse observes the client self-administering the
the nurse notes that the client’s dressing is moist, which medication. Which action indicates that the client is
action is most appropriate to take first? performing the procedure correctly?
1. The nurse changes the dressing. 1. The client assumes a supine position.
2. The nurse reinforces the dressing. 2. The client tilts her head to the side.
3. The nurse removes the dressing. 3. The client inverts the drug container.
4. the nurse documents the findings. 4. The client inhales with each spray.
The client with acromegaly will undergo a transsphenoidal
A client experiences recurrent pain along the sciatic nerve. The hypophysectomy after a short course of theraphy with
client is scheduled for a myelogram. bromocriptine (Parlodel).
33. Because bromocriptine (Parlodel) may cause postural
25. When the nurse describes the myelogram procedure to hypotension, which nursing instruction is most
the client, which statement is most accurate? appropriate?
1. part of the test involves a lumbar puncture. 1. Lie down for ½ hour after taking the
2. You will be asked to change positions medication.
frequently. 2. Avoid taking elevators in tall buildings.
3. Dye will be instilled into a vein in your arm. 3. Rise slowly from a sitting or lying position.
4. Light anesthesia is administered during the 4. Have your blood pressure taken once a week.
test.
A 35 year-old woman is undergoing test to determine why she
26. Postoperatively, the client who has had a cataract has stopped menstruating. One test that the client undergoes is
extraction tells the nurse that he is experiencing severe a radioactive iodine uptake test.
pain in his operative eye. Which nursing action is most
appropriate? 34. When the test is completed, which of the nurse’s
1. Report the finding to the nurse in charge. statements is accurate?
2. Give the client’s prescribed analgesic. 1. “You must remain isolated until your radiation
3. Assess the client’s pupil response with a is decreased.”
penlight. 2. “You are free to go without further
4. Reposition the client on the operative. Side. precautionary instruction.”
3. “You must follow special precaution for a short
27. It is essential that the nurse withholds medication period of time.”
administration and notifies the physician if which drug is 4. “You will be given an antidote for reducing the
ordered for a client with glaucoma? radioactivity.”
1. Atropine sulfate
2. Morphine sulfate The client is stable condition returns to the nursing unit after
3. Magnesium sulfate having a subtotal thyroidectomy.
4. Ferrous sulfate 35. In which position is it most appropriate to maintain the
client following a subtotal thyroidectomy?
28. Which instrument is most appropriate for the nurse to 1. Supine
use for the purpose of testing the client’s hearing acuity? 2. Sims
1. Otoscope 3. Fowler’s
2. Tuning fork 4. Recumbent
3. Reflex hammer
4. Stethoscope The care plan indicates that the nurse should assess the
Chvostek’s sign if hypocalcemia is suspected.
A client asks the nurse why adults do not experience middle ear
infections as frequently as children do. 36. Which technique best describes how Chvostek’s sign is
elicited?
29. The nurse is most correct in explaining that, in a child, 1. The nurse lightly taps over the client facial
organisms travel more easily from the nasopharynx to nerve.
the middle ear because the Eustachian tube is. 2. The nurse strokes the sole of the client’s foot.

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 3. The nurse dorsiflexes each of the client’s feet. 4. The client inverts each vial prior to
4. the nurse asks the client to touch her nose. withdrawing the specified amount of insulin.

A client with hyppoparathyroidism develops tetany. 45. When the client practices self-administration of the
insulin, which action is correct?
37. If emergency drugs are available, which one can the 1. Piercing the skin at a 30-degree angle.
nurse expert the physician will order for intravenous 2. Using a syringe calibrated in minims.
administration? 3. Using a 2-inch needle on the syringe
1. Calcium gluconate 4. Rotating the sites of each injection.
2. Ferrous sulfate
3. Potassium chloride 46. Which instruction by the nurse should be given to the
4. Sodium bicarbonate. client regarding insulin administration during sick days?
1. Monitor blood glucose levels every 2 to 4
The physician orders a 24-hour urine collection to aid in the hours.
diagnosis of Cushing’s syndrome. 2. Eat candy or sugar frequently.
3. Attempt to drink a high-calorie beverage
38. The nurse most accurate in instructing the client that the every hour.
urine collection will begin 4. Test urine daily fro protein.
1. With the client’s next voiding.
2. After the client’s next voiding. 47. As the nurse prepares to withdraw the furosemide (Lasix)
3. At midnight. from the ampule the best technique for removing the
4. At noontime. medication is to.
1. Allow the ampule to stand undisturbed for a
A 5-hour glucose test is ordered to determine if the client has few minutes.
functional hypoglycemia. 2. Tap the ampule stem with the fingernail a few
times.
39. Which nursing instruction concerning the test procedure 3. Hold the ampule upside down, then flip it right
is most accurate? side up.
1. You need to eat a large meal just before the 4. Roll the ampule gently between the palms of
test. the hands.
2. Bring a voided urine specimen to the
laboratory. 48. The best evidence that turosemide (Lasix) has had a
3. You can have liquids, like coffee, before the therapeutic effect is that the client’s.
test. 1. Pulse becomes slower.
4. You will be given a sweetened drink before 2. Blood pressure stabilizes.
the test. 3. Urinary output increases.
4. Anxiety is diminished.
A nurse participates in a community-wide screening to identify
adults who may have undiagnosed diabetes mellitus. 49. The nurse should instruct the client to take his oral
furosemide (Lasix) at what time of the day?
40. If the screening includes a measurement of postprandial 1. Before bedtime.
blood sugar, the nurse is correct in explaining that blood 2. When arising.
will be drawn approximately 2 hours. 3. With his main meal.
1. Before breakfast. 4. In the late afternoon.
2. After meal.
3. Before bedtime. 50. When teaching the client about the side effects of
4. After a fast. furosemide (Lasix), the nurse instructs him that he will
need to eat foods high in which mineral?
41. Which statement indicates that a client with an elevated 1. Potassium.
2-hour postprandial blood sugar understands the 2. Sodium
significance of the screening test? 3. Calcium
1. “I need to eat less frequently.” 4. Iron
2. “I need to stop eating candy.” 51. The nurse instructs the client taking furosemide (Lasix) to
3. “I need to consult my physician.” monitor his urine output. The rationale for the nurse’s
4. “I need to begin taking insulin.’ instruction is that the use of furosemide (Lasix) may lead
to which condition?
The physician prescribes glyburide (DiaBeta) orally for the client 1. Dehydration
with type II diabetes mellitus. 2. Fluid overload
3. Hypernatremia
42. When the client asks why his diabetic relative cannot take 4. Hyperkalemia
his insulin orally, the best answer is that insulin is
1. Inactivated by digestive enzymes. The client is scheduled for a stress electrocardiogram (ECG).
2. Absorbed too quickly in the stomach.
3. Irritating to the gastric mucosa. 52. When the client asks why the physician ordered the ECG,
4. Incompatible with many foods. it is most correct for the nurse to explain that a stress
ECG.
1. Shows how the heart performs during
The nurse plans to monitor the client’s response to insulin exercise.
therapy closely with an electronic glucometer. 2. Determine his potential target heart rate.
43. When the nurse monitors the client’s blood sugar using 3. Verifies how much he needs to improve his
an electronic glucometer, which action is correct? fitness.
1. Clean the client’s finger with povidone iodine 4. Can predict if he will have a heart attack soon.
(Betadine).
2. Apply a rubber band around the test finger. 53. Which side effect is most closely associated with the use
3. Pierce the central pad of the client’s finger. of nitrogen tablets?
4. Apply a large drop of blood to a test strip or 1. Headache
area. 2. Backache
44. Which action best indicates that the client needs more 3. Diarrhea
practice in combining two insulins in one syringe? 4. Jaundice
1. The client rolls the vial of intermediate-acting
insulin to mix it with its additive. 54. It is most accurate for the nurse to tell the client that if
2. The client instills air into both the fast-acting his chest pain is not relieved after taking one
and intermediate-acting insulin vials. nitroglycerin tablet he should.
3. The client instills the intermediate-acting 1. Take another tablet in 5 minutes.
insulin into the vial of rapid-acting insulin. 2. Drive of the emergency department.

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 3. Call his physician without delay.
4. Swallow two additional tablets. The client who is awaiting a PTCA has been taking one baby
aspirin daily per the advice of his physician.
55. Which nursing action is most appropriate when applying
the transdermal patch? 63. The best explanation for the drug therapy in this situation
1. Rotate the application site. is that aspirin tends to
2. Squeeze the drug reservoir. 1. Relieve chest pain
3. Tape the patch to the chest. 2. Prevent blood clots
4. Apply ice to the skin area. 3. Reduce muscle spasms
4. Reduce joint inflammation.
56. Prior to the catheterization and coronary arteriogram, it is
essential that the nurse ask the client if he allergic to 64. When the client returns to his room following the PTCA
iodine or. procedure, which assessment finding should be reported
1. Penicillin. immediately to the physician?
2. Morphine. 1. Urine output of 100 mL/h
3. Shellfish 2. Blood pressure of 108/68 mm Hg
4. Eggs. 3. Dry mouth
4. Chest pain
57. The client who has been experiencing increased incidence
of chest pain will undergo a heart catheterization and The client who has a previous PTCA is now scheduled for a
coronary arteriogram. To reduce the client’s anxiety, it is coronary artery bypass graft (CBAG).
best for the nurse to.
65 . Immediately after returning to the unit, the nurse
1. Teach the client how coronary artery disease assesses the client’s leg incision. The nurse is aware that
is usually treated. the most common blood vessel used in CABG surgery is
2. Listen to the client express his feelings about the
his condition.
3. Explain to the client how well others have 1. Saphenous vein.
done having this test. 2. Femoral artery.
4. Avoid discussing the heart catheterization until 3. Popliteal vein.
client has relaxed. 4. Iliac artery.

58. The nurse implements the teaching plan for cardiac The physician orders a patient-controlled analgesia (PCA)
catheterization and coronary arteriogram. infuser pump for the client following CABG surgery.
1. The client says that he will be able to hear
beating in his chest. 66. The nurse instructs the client about the use of the PCA
2. The client says that he will experience a heavy pump. Which information is most important for the nurse to
sensation all over his body. provide?
3. The client says that he will be anesthetized 1. Press the control button when pain medication is needed.
and won’t feel any discomfort. 2. Call the nurse each time the PCA pump needs to be used.
4. The client says that he will feel a warm 3. Use the PCA pump only when the pain is severe.
sensation as the dye is instilled. 4. Frequent use of the PCA pump can cause addiction.

The femoral artery is the site used to thread the heart catheter. 67. After the CABG surgery, which assessment finding
provides the best evidence that collateral circulation
59. After the coronary arteriogram, the nurse correctly keeps at the donor graft site is adequate?
the client flat in bed with the affected leg. 1. The client is free of chest pain.
1. Extended 2. The toes are warm and nonedematous.
2. Flexed 3. The client moves his leg easily.
3. Abducted 4. The heart rate remains regular.
4. Abducted. 68. Which drug should the nurse plan to have on hand
in case the client who receives streptokinase
60. After the femoral artery has been cannulated, the most (Streptase) develops an allergic reaction?
important physical assessment the nurse should plan is 1. Vitamin K (Synkayvite)
to 2. Heparin sodium (Liquaemin sodium)
1. Palpate the client’s distal peripheral pulses. 3. Diphenhydramine (Benadryl)
2. Auscultate the client’s heart and lung sounds. 4. Warfarin sodium (Coumadin)
3. Percuss all four quadrants of the client’s A 65 year-old woman collapse in the hospital elevator while
abdomen. coming to visit a family member.
4. Inspect the skin integrity in the client’s groin. 69. The first action the nurse who discovers her should
take is to
Based on the results of the coronary arteriogram, the physician 1. Open her airway.
recommends that the client undergo percutaneous transluminal 2. Give two breaths.
coronary angioplasty (PTCA). 3. Shake her gently.
4. Call a code blue.
61. If the client understands his physician’s explanation of 70. Which technique is best for the nurse to use to open the
the PTCA procedure, he will describe that a airway of the person who is not breathing?
1. Balloon-tipped catheter will be inserted into a 1. Elevate the neck.
coronary artery. 2. Lift the chin.
2. Teflon graft will be used to replace an area of 3. Press on the jaws.
weakened heart muscle. 4. Clear the mouth.
3. Section of vein from his leg will be grafted 71. The best method fort determining if rescue breathing
around a narrowed coronary artery. should be performed is to
4. Battery-operated pacemaker will be implanted 1. Observe the victim’s skin color.
to maintain his heart rate. 2. Feel for pulsations at the neck.
3. Listen for spontaneous breathing.
While waiting to undergo PTCA, the client takes propranolol 4. Blow air into the victim’s mouth.
hydrochloride (Inderal). 72. During cardiopulmonary resuscitation (CPR), the nurse
compresses the chest of an adult victim at a rate of no less than
62. When the client asks the nurse how this drug helps to 1. 15 compressions per minute.
prevent angina, the best explanation is that it 2. 40 compressions per minute.
1. Promotes excretion of body fluid 3. 80 compressions per minute.
2. Reduces the rate of heart contribution. 4. 100 compressions per minute.
3. Alters pain receptors in the brain. 73. When two rescuers perform CPR, the rate of compressions
4. Dilates the major coronary arteries. to ventilations is.

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 1. 15 compressions to 2 breaths. 3. Hydration determines when the client needs to be
2. 5 compressions to 1 breath. transfused.
3. 1 compression for each breath. 4. Hydration indicates when fluids should be
4. 1 compression to 5 breaths. increased.

A physician writes an order for the application of wet-to-dry

dressing over the venous stasis ulcers.

74. Which evidence best determines when the cardiac 83. When the client asks the nurse why the dressings are being
compressions can be discontinued? applied, the best explanation is that these dressing help to
1. The victim’s color improves. 1. Prevent wound infections.
2. The pupils become dilated. 2. Remove dead cells and tissue.
3. A pulse can be palpated. 3. Absorb blood and drainage.
4. The victim begins to vomit. 4. Protect the skin from injury.
84. The client develops a thrombus in one of her leg veins.
75. The nurse monitors the client’s lab values because of the When the nurse assesses for Homans’ sign.
large doses of diuretics the client received to treat her 1. the client will experience sharp calf pain
pulmonary edema. Which lab value must the nurse report immediately.
immediately to the physician? 2. The client will complain of sudden numbness in
1. Sodium 137 mEq/L her foot.
2. Potassium 2.5 mEq/L 3. The client will be unable to bend her knee when
3. Chloride 97 mEq/L asked.
4. Bicarbonate 25 mEq/L 4. The client will feel tingling throughout her affected
leg.
76. If the clients develops digitalis toxicity, she is most likely to
exhibit. The physician orders heparin calcium (Calciparine) 7500 U
1. Anorexia and nausea subcutaneously.
2. Dizziness and insomnia.
3. Pinpoint pupils and double vision. 85. When the client asks why she is receiving the medication,
4. Ringing in the ears and itchy skin. the most appropriate nursing response is that heparin
1. Helps shrink blood clots.
77. Before administering the digoxin 2. Helps dissolve blood clots.
(Lanoxin) to the client, it essential that the nurse assess 3. Prevent more clots from forming
the 4. Prevents the clot from dislodging.
1. Heart rate. 86. When the nurse withdraws the heparin calcium from the
2. Blood pressure. multidose vial, which technique is most accurate?
3. Heart sounds. 1. The nurse removes the rubber stopper in the top of
4. Lung sounds. vial.
2. The nurse instills an equal volume of air as liquid to be
78. Before cardioversion is attempted, the nurse is most withdrawn
correct in withholding which prescribed medication? 3. The nurse mixes the drug by rolling it in the palms of
1. Diazepam (Valium) the hands
2. Digoxin (Lanoxin) 4. the nurse shakes the drug vigorously to distribute the
3. Heaprin (Lipo-sodium) drug evenly
4. Glyburide (DiaBeta) 87. When the nurse administers the heparin subcutaneously to
the client of average weight for her height, which action is most
79. The best evidence that the cardioversion procedure accurate?
has been successful is 1. The nurse selects the dorsogluteal site
1. The client regains 2. The nurse uses a 220gauge, 1 ½ inch needle
consciousness immediately. 3. The nurse inserts the needle at 45o angle
2. Normal sinus cardiac rhythm 4. the nurse massages the site immediately after ward
is restored. A nurse applies prolonged pressure to an injection site of client
3. The apical heart rate equals the radial who is receiving anticoagulant therapy
rate. 88. The nurse actions is
4. The pulse pressure is approximately 40 1. inappropriate because it promotes hematoma
mm Hg. formation
2. inappropriate because it delays drug absorption
80. As part of the discharge instructions, the nurse most 3. appropriate because it distributes the drug evenly
correctly instructs the client with an artificial pacemakers 4. appropriate because it diminishes blood loss
that a sign pacemaker malfunction. 89. The first action the nurse should take if phlebitis is
1. Tingling in the chest pain. suspected at an intravenous site is to
2. Dizziness during activity. 1. elevate the affected extremity on pillows
3. Pain radiating to the arm. 2. apply pressure to the intravenous insertion site
4. Tenderness beneath the skin. 3. administer the intravenous solution at a fast rate
4. remove the needle or catheter from the current site
81. The best location for the nurse to auscultate the The nurse prepares to use a Doppler ultrasound device to
sounds from the mitral valve is assess blood flow through the dorsalis pedis artery
1. At the fifth intercostals space
in the midclavicular line. 90. Which technique is most accurate when using the Doppler
2. At the fourth intercostals space to device?
the sternum. 1. the nurse places the probe beside the ankle
3. At the second intercostals space to the 2. the nurse applies acoustic gel to the skin
right of sternum. 3. the nurse records the time of capillary refill
4. At the second intercostals space to the left 4. the nurse measures the temperature of the skin
of sternum.
An 18 year old college student has been feeling extremely tired
82. In the postoperative period, the nurse frequently and makes an appointment at the university’s health office
assesses the client’s fluid status. What is the rationale
for the nurse’s action? 91. Which laboratory test can the nurse expect to be lower than
normal if the cause of the client’s fatigue is related to iron-
1. Urinary output retention is common after a heart deficiency anemia?
transplant. 1. Prothrombin time
2. Urine output is an indication of perfusion to the 2. Bleeding time
kidneys. 3. Fibrinogen level
4. Hemoglobin level

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92. For the best absorption of oral iron preparation, the nurse
most accurately instruct the client to take ferrous sulfate
1. between meals
2. with each meal
3. just before eating
4. just before bedtime
93. To maximize the absorption of the iron supplement the
nurse most accurate advises the client to take the table with
1. milk
2. tea
3. a soft drink
4. orange juice
94. The nurse instructs the client about administering of the
liquid iron preparation. Which instruction is most accurate?
1. use a straw
2. pour it in a paper cup
3. take it cover ice
4. mix it with milk
95. Which muscle is best for the nurse to plan to use when
giving the injection by Z-track technique?
1. deltoid
2. trapezius
3. gluteus medius
4. latissimus dorsi
Laboratory test result indicate that the client with leukemia has
a low platelet count.

97. Based on the client’s laboratory results, which nursing

intervention is most appropriate at this time?
1. limit the client’s visitors to family
2. place the client in protective isolation
3. use small-gauge needle for injection
4. provide rest periods between activities
The physician informs the client with polycythemia that a
phlebotomy will be performed
98. The best evidence that the client understand the physician
explanation is when he tells the nurse that
1. blood will be removed from his vein
2. tourniquets will be applied to his arms
3. some veins will be surgically occluded
4. he will receive a blood transfusion
The physician orders several laboratory tests for the client
suspected of having AIDS
99. Which laboratory test is most significant for diagnosing
antibodies to the human immunodeficiency virus (HIV)?”
1. Schick test
2. Dick test
3. enzyme-linked immunosorbent assay (ELISA)
4. venereal disease research laboratory (VDRL) test

100. The nurse explains to the client the anatomic location for
the bone marrow aspiration. Which area should the client point
to when to identify the site where the specimen will be taken?
1. the posterior hip
2. the lower spine
3. the upper arm
4. the groin area