PNLE 1 For Foundation of Professional Nursing Practice PDF

PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE 1. The nurse In-charge in labor and delivery unit 6. Nurse Gail places a client in a four-point restraint administered a dose of terbutaline to a client without following orders from the ph...

PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE 1. The nurse In-charge in labor and delivery unit 6. Nurse Gail places a client in a four-point restraint administered a dose of terbutaline to a client without following orders from the physician. The client care plan checking the client’s pulse. The standard that would be should include: used to determine if the nurse was negligent is: A. Assess temperature frequently. A. The physician’s orders. B. Provide diversional activities. B. The action of a clinical nurse specialist who is C. Check circulation every 15-30 minutes. recognized expert in the field. D. Socialize with other patients once a shift. C. The statement in the drug literature about 7. A male client who has severe burns is receiving H2 administration of terbutaline. receptor antagonist therapy. The nurse In-charge knows D. The actions of a reasonably prudent nurse the purpose of this therapy is to: with similar education and experience. 2. Nurse Trish is caring for a female client with a history of A. Prevent stress ulcer GI bleeding, sickle cell disease, and a platelet count of B. Block prostaglandin synthesis 22,000/μl. The female client is dehydrated and receiving C. Facilitate protein synthesis. dextrose 5% in half-normal saline solution at 150 ml/hr. The D. Enhance gas exchange client complains of severe bone pain and is scheduled to 8. The doctor orders hourly urine output measurement for receive a dose of morphine sulfate. In administering the a postoperative male client. The nurse Trish records the medication, Nurse Trish should avoid which route? following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which A. I.V action should the nurse take? B. I.M C. Oral A. Increase the I.V. fluid infusion rate D. S.C B. Irrigate the indwelling urinary catheter 3. Dr. Garcia writes the following order for the client who C. Notify the physician has been recently admitted “Digoxin.125 mg P.O. once D. Continue to monitor and record hourly urine daily.” To prevent a dosage error, how should the nurse output document this order onto the medication administration 9. Tony, a basketball player twist his right ankle while record? playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 A. “Digoxin.1250 mg P.O. once daily” minutes, which statement by Tony suggests that ice B. “Digoxin 0.1250 mg P.O. once daily” application has been effective? C. “Digoxin 0.125 mg P.O. once daily” D. “Digoxin.125 mg P.O. once daily” A. “My ankle looks less swollen now”. 4. A newly admitted female client was diagnosed with deep B. “My ankle feels warm”. vein thrombosis. Which nursing diagnosis should receive C. “My ankle appears redder now”. the highest priority? D. “I need something stronger for pain relief” 10.The physician prescribes a loop diuretic for a client. A. Ineffective peripheral tissue perfusion When administering this drug, the nurse anticipates that related to venous congestion. the client may develop which electrolyte imbalance? B. Risk for injury related to edema. C. Excess fluid volume related to peripheral A. Hypernatremia vascular disease. B. Hyperkalemia D. Impaired gas exchange related to increased C. Hypokalemia blood flow. D. Hypervolemia 5. Nurse Betty is assigned to the following clients. The client 11.She finds out that some managers have benevolent- that the nurse would see first after endorsement? authoritative style of management. Which of the following behaviors will she exhibit most likely? A. A 34 year-old post operative appendectomy client of five hours who is complaining of A. Have condescending trust and confidence in pain. their subordinates. B. A 44 year-old myocardial infarction (MI) B. Gives economic and ego awards. client who is complaining of nausea. C. Communicates downward to staffs. C. A 26 year-old client admitted for dehydration D. Allows decision making among subordinates. whose intravenous (IV) has infiltrated. 12. Nurse Amy is aware that the following is true about D. A 63 year-old post operative’s abdominal functional nursing hysterectomy client of three days whose incisional dressing is saturated A. Provides continuous, coordinated and with serosanguinous fluid. comprehensive nursing services. B. One-to-one nurse patient ratio.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE C. Emphasize the use of group collaboration. 20.Nurse Hazel will administer a unit of whole blood, which D. Concentrates on tasks and activities. priority information should the nurse have about the 13.Which type of medication order might read “Vitamin K client? 10 mg I.M. daily × 3 days?” A. Blood pressure and pulse rate. A. Single order B. Height and weight. B. Standard written order C. Calcium and potassium levels C. Standing order D. Hgb and Hct levels. D. Stat order 21. Nurse Michelle witnesses a female client sustain a fall 14.A female client with a fecal impaction frequently and suspects that the leg may be broken. The nurse takes exhibits which clinical manifestation? which priority action? A. Increased appetite A. Takes a set of vital signs. B. Loss of urge to defecate B. Call the radiology department for X-ray. C. Hard, brown, formed stools C. Reassure the client that everything will be D. Liquid or semi-liquid stools alright. 15.Nurse Linda prepares to perform an otoscopic D. Immobilize the leg before moving the client. examination on a female client. For proper visualization, 22.A male client is being transferred to the nursing unit for the nurse should position the client’s ear by: admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority A. Pulling the lobule down and back action in the care of this client? B. Pulling the helix up and forward C. Pulling the helix up and back A. Place client on reverse isolation. D. Pulling the lobule down and forward B. Admit the client into a private room. 16. Which instruction should nurse Tom give to a male C. Encourage the client to take frequent rest client who is having external radiation therapy: periods. D. Encourage family and friends to visit. A. Protect the irritated skin from sunlight. 23.A newly admitted female client was diagnosed with B. Eat 3 to 4 hours before treatment. agranulocytosis. The nurse formulates which priority C. Wash the skin over regularly. nursing diagnosis? D. Apply lotion or oil to the radiated area when it is red or sore. A. Constipation 17.In assisting a female client for immediate surgery, the B. Diarrhea nurse In-charge is aware that she should: C. Risk for infection D. Deficient knowledge A. Encourage the client to void following 24.A male client is receiving total parenteral nutrition preoperative medication. suddenly demonstrates signs and symptoms of an air B. Explore the client’s fears and anxieties about embolism. What is the priority action by the nurse? the surgery. C. Assist the client in removing dentures and A. Notify the physician. nail polish. B. Place the client on the left side in the D. Encourage the client to drink water prior to Trendelenburg position. surgery. C. Place the client in high-Fowlers position. 18. A male client is admitted and diagnosed with acute D. Stop the total parenteral nutrition. pancreatitis after a holiday celebration of excessive food 25.Nurse May attends an educational conference on and alcohol. Which assessment finding reflects this leadership styles. The nurse is sitting with a nurse diagnosis? employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and A. Blood pressure above normal range. directive. The nurse determines that the leadership style B. Presence of crackles in both lung fields. used at the trauma center is: C. Hyperactive bowel sounds D. Sudden onset of continuous epigastric and A. Autocratic. back pain. B. Laissez-faire. 19. Which dietary guidelines are important for nurse Oliver C. Democratic. to implement in caring for the client with burns? D. Situational 26.The physician orders DS 500 cc with KCl 10 mEq/liter at A. Provide high-fiber, high-fat diet 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. B. Provide high-protein, high-carbohydrate diet. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be C. Monitor intake to prevent weight gain. added to the IV solution? D. Provide ice chips or water intake.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE A..5 cc 33.In preventing the development of an external rotation B. 5 cc deformity of the hip in a client who must remain in bed for C. 1.5 cc any period of time, the most appropriate nursing action D. 2.5 cc would be to use: 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will A. Trochanter roll extending from the crest of deliver this amount is: the ileum to the midthigh. B. Pillows under the lower legs. A. 50 cc/ hour C. Footboard B. 55 cc/ hour D. Hip-abductor pillow C. 24 cc/ hour 34.Which stage of pressure ulcer development does the D. 66 cc/ hour ulcer extend into the subcutaneous tissue? 28.The nurse is aware that the most important nursing action when a client returns from surgery is: A. Stage I B. Stage II A. Assess the IV for type of fluid and rate of C. Stage III flow. D. Stage IV B. Assess the client for presence of pain. 35.When the method of wound healing is one in which C. Assess the Foley catheter for patency and wound edges are not surgically approximated and urine output integumentary continuity is restored by granulations, the D. Assess the dressing for drainage. wound healing is termed 29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? A. Second intention healing B. Primary intention healing A. BP – 80/60, Pulse – 110 irregular C. Third intention healing B. BP – 90/50, Pulse – 50 regular D. First intention healing C. BP – 130/80, Pulse – 100 regular 36.An 80-year-old male client is admitted to the hospital D. BP – 180/100, Pulse – 90 irregular with a diagnosis of pneumonia. Nurse Oliver learns that the 30.Which is the most appropriate nursing action in client lives alone and hasn’t been eating or drinking. When obtaining a blood pressure measurement? assessing him for dehydration, nurse Oliver would expect to find: A. Take the proper equipment, place the client in a comfortable position, and record the A. Hypothermia appropriate information in the client’s chart. B. Hypertension B. Measure the client’s arm, if you are not sure C. Distended neck veins of the size of cuff to use. D. Tachycardia C. Have the client recline or sit comfortably in a 37.The physician prescribes meperidine (Demerol), 75 mg chair with the forearm at the level of the I.M. every 4 hours as needed, to control a client’s heart. postoperative pain. The package insert is “Meperidine, 100 D. Document the measurement, which mg/ml.” How many milliliters of meperidine should the extremity was used, and the position that client receive? the client was in during the measurement. 31.Asking the questions to determine if the person A. 0.75 understands the health teaching provided by the nurse B. 0.6 would be included during which step of the nursing C. 0.5 process? D. 0.25 38. A male client with diabetes mellitus is receiving insulin. A. Assessment Which statement correctly describes an insulin unit? B. Evaluation C. Implementation A. It’s a common measurement in the metric D. Planning and goals system. 32.Which of the following item is considered the single B. It’s the basis for solids in the avoirdupois most important factor in assisting the health professional in system. arriving at a diagnosis or determining the person’s needs? C. It’s the smallest measurement in the apothecary system. A. Diagnostic test results D. It’s a measure of effect, not a standard B. Biographical date measure of weight or quantity. C. History of present illness 39.Nurse Oliver measures a client’s temperature at 102° F. D. Physical examination What is the equivalent Centigrade temperature?  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE A. 40.1 °C D. Auscultation, percussion, and palpation. B. 38.9 °C 46. Nurse Betty is assessing tactile fremitus in a client with C. 48 °C pneumonia. For this examination, nurse Betty should use D. 38 °C the: 40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One A. Fingertips of the first physical signs of aging is: B. Finger pads C. Dorsal surface of the hand A. Accepting limitations while developing D. Ulnar surface of the hand assets. 47. Which type of evaluation occurs continuously B. Increasing loss of muscle tone. throughout the teaching and learning process? C. Failing eyesight, especially close vision. D. Having more frequent aches and pains. A. Summative 41.The physician inserts a chest tube into a female client to B. Informative treat a pneumothorax. The tube is connected to water-seal C. Formative drainage. The nurse in-charge can prevent chest tube air D. Retrospective leaks by: 48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John A. Checking and taping all connections. should instruct her to have mammogram how often? B. Checking patency of the chest tube. C. Keeping the head of the bed slightly A. Twice per year elevated. B. Once per year D. Keeping the chest drainage system below the C. Every 2 years level of the chest. D. Once, to establish baseline 42.Nurse Trish must verify the client’s identity before 49.A male client has the following arterial blood gas values: administering medication. She is aware that the safest way pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 to verify identity is to: 26mEq/L. Based on these values, Nurse Patricia should expect which condition? A. Check the client’s identification band. B. Ask the client to state his name. A. Respiratory acidosis C. State the client’s name out loud and wait a B. Respiratory alkalosis client to repeat it. C. Metabolic acidosis D. Check the room number and the client’s D. Metabolic alkalosis name on the bed. 50.Nurse Len refers a female client with terminal cancer to 43.The physician orders dextrose 5 % in water, 1,000 ml to a local hospice. What is the goal of this referral? be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate A. To help the client find appropriate treatment of: options. B. To provide support for the client and family A. 30 drops/minute in coping with terminal illness. B. 32 drops/minute C. To ensure that the client gets counseling C. 20 drops/minute regarding health care costs. D. 18 drops/minute D. To teach the client and family about cancer 44.If a central venous catheter becomes disconnected and its treatment. accidentally, what should the nurse in-charge do 51.When caring for a male client with a 3-cm stage I immediately? pressure ulcer on the coccyx, which of the following actions can the nurse institute independently? A. Clamp the catheter B. Call another nurse A. Massaging the area with an astringent every C. Call the physician 2 hours. D. Apply a dry sterile dressing to the site. B. Applying an antibiotic cream to the area 45.A female client was recently admitted. She has fever, three times per day. weight loss, and watery diarrhea is being admitted to the C. Using normal saline solution to clean the facility. While assessing the client, Nurse Hazel inspects the ulcer and applying a protective dressing as client’s abdomen and notice that it is slightly concave. necessary. Additional assessment should proceed in which order: D. Using a povidone-iodine wash on the ulceration three times per day. A. Palpation, auscultation, and percussion. 52.Nurse Oliver must apply an elastic bandage to a client’s B. Percussion, palpation, and auscultation. ankle and calf. He should apply the bandage beginning at C. Palpation, percussion, and auscultation. the client’s:  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE A. Knee 59.Nurse Meredith is in the process of giving a client a bed B. Ankle bath. In the middle of the procedure, the unit secretary C. Lower thigh calls the nurse on the intercom to tell the nurse that there D. Foot is an emergency phone call. The appropriate nursing action 53.A 10 year old child with type 1 diabetes develops is to: diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to A. Immediately walk out of the client’s room this child? and answer the phone call. B. Cover the client, place the call light within A. Hypernatremia reach, and answer the phone call. B. Hypokalemia C. Finish the bed bath before answering the C. Hyperphosphatemia phone call. D. Hypercalcemia D. Leave the client’s door open so the client can 54.Nurse Len is administering sublingual nitrglycerin be monitored and the nurse can answer the (Nitrostat) to the newly admitted client. Immediately phone call. afterward, the client may experience: 60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive A. Throbbing headache or dizziness cough. Nurse Janah plans to implement which intervention B. Nervousness or paresthesia. to obtain the specimen? C. Drowsiness or blurred vision. D. Tinnitus or diplopia. A. Ask the client to expectorate a small amount 55.Nurse Michelle hears the alarm sound on the telemetry of sputum into the emesis basin. monitor. The nurse quickly looks at the monitor and notes B. Ask the client to obtain the specimen after that a client is in a ventricular tachycardia. The nurse rushes breakfast. to the client’s room. Upon reaching the client’s bedside, the C. Use a sterile plastic container for obtaining nurse would take which action first? the specimen. D. Provide tissues for expectoration and A. Prepare for cardioversion obtaining the specimen. B. Prepare to defibrillate the client 61. Nurse Ron is observing a male client using a walker. The C. Call a code nurse determines that the client is using the walker D. Check the client’s level of consciousness correctly if the client: 56.Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting A. Puts all the four points of the walker flat on the client is to stand: the floor, puts weight on the hand pieces, and then walks into it. A. On the unaffected side of the client. B. Puts weight on the hand pieces, moves the B. On the affected side of the client. walker forward, and then walks into it. C. In front of the client. C. Puts weight on the hand pieces, slides the D. Behind the client. walker forward, and then walks into it. 57.Nurse Janah is monitoring the ongoing care given to the D. Walks into the walker, puts weight on the potential organ donor who has been diagnosed with brain hand pieces, and then puts all four points of death. The nurse determines that the standard of care had the walker flat on the floor. been maintained if which of the following data is observed? 62.Nurse Amy has documented an entry regarding client care in the client’s medical record. When checking the entry, the nurse realizes that incorrect information was A. Urine output: 45 ml/hr documented. How does the nurse correct this error? B. Capillary refill: 5 seconds C. Serum pH: 7.32 D. Blood pressure: 90/48 mmHg A. Erases the error and writes in the correct 58. Nurse Amy has an order to obtain a urinalysis from a information. male client with an indwelling urinary catheter. The nurse B. Uses correction fluid to cover up the avoids which of the following, which contaminate the incorrect information and writes in the specimen? correct information. C. Draws one line to cross out the incorrect information and then initials the change. A. Wiping the port with an alcohol swab before D. Covers up the incorrect information inserting the syringe. completely using a black pen and writes in B. Aspirating a sample from the port on the the correct information drainage bag. 63.Nurse Ron is assisting with transferring a client from the C. Clamping the tubing of the drainage bag. operating room table to a stretcher. To provide safety to D. Obtaining the specimen from the urinary the client, the nurse should: drainage bag.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE A. Moves the client rapidly from the table to 69.Patient’s refusal to divulge information is a limitation the stretcher. because it is beyond the control of Tifanny”. What type of B. Uncovers the client completely before research is appropriate for this study? transferring to the stretcher. C. Secures the client safety belts after A. Descriptive- correlational transferring to the stretcher. B. Experiment D. Instructs the client to move self from the C. Quasi-experiment table to the stretcher. D. Historical 64.Nurse Myrna is providing instructions to a nursing 70.Nurse Ronald is aware that the best tool for data assistant assigned to give a bed bath to a client who is on gathering is? contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items A. Interview schedule when giving bed bath? B. Questionnaire C. Use of laboratory data A. Gown and goggles D. Observation B. Gown and gloves 71.Monica is aware that there are times when only C. Gloves and shoe protectors manipulation of study variables is possible and the D. Gloves and goggles elements of control or randomization are not attendant. 65. Nurse Oliver is caring for a client with impaired mobility Which type of research is referred to this? that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that A. Field study the client use which of the following assistive devices that B. Quasi-experiment would provide the best stability for ambulating? C. Solomon-Four group design D. Post-test only design A. Crutches 72.Cherry notes down ideas that were derived from the B. Single straight-legged cane description of an investigation written by the person who C. Quad cane conducted it. Which type of reference source refers to this? D. Walker 66.A male client with a right pleural effusion noted on a A. Footnote chest X-ray is being prepared for thoracentesis. The client B. Bibliography experiences severe dizziness when sitting upright. To C. Primary source provide a safe environment, the nurse assists the client to D. Endnotes which position for the procedure? 73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any A. Prone with head turned toward the side action that will cause the patient harm. This is the meaning supported by a pillow. of the bioethical principle: B. Sims’ position with the head of the bed flat. C. Right side-lying with the head of the bed A. Non-maleficence elevated 45 degrees. B. Beneficence D. Left side-lying with the head of the bed C. Justice elevated 45 degrees. D. Solidarity 67.Nurse John develops methods for data gathering. Which 74.When a nurse in-charge causes an injury to a female of the following criteria of a good instrument refers to the patient and the injury caused becomes the proof of the ability of the instrument to yield the same results upon its negligent act, the presence of the injury is said to exemplify repeated administration? the principle of: A. Validity A. Force majeure B. Specificity B. Respondeat superior C. Sensitivity C. Res ipsa loquitor D. Reliability D. Holdover doctrine 68.Harry knows that he has to protect the rights of human 75.Nurse Myrna is aware that the Board of Nursing has research subjects. Which of the following actions of Harry quasi-judicial power. An example of this power is: ensures anonymity? A. The Board can issue rules and regulations A. Keep the identities of the subject secret that will govern the practice of nursing B. Obtain informed consent B. The Board can investigate violations of the C. Provide equal treatment to all the subjects of nursing law and code of ethics the study. C. The Board can visit a school applying for a D. Release findings only to the participants of permit in collaboration with CHED the study D. The Board prepares the board examinations  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE 76. When the license of nurse Krina is revoked, it means 82.John plans to use a Likert Scale to his study to determine that she: the: A. Is no longer allowed to practice the A. Degree of agreement and disagreement profession for the rest of her life B. Compliance to expected standards B. Will never have her/his license re-issued C. Level of satisfaction since it has been revoked D. Degree of acceptance C. May apply for re-issuance of his/her license 83.Which of the following theory addresses the four modes based on certain conditions stipulated in RA of adaptation? 9173 D. Will remain unable to practice professional A. Madeleine Leininger nursing B. Sr. Callista Roy 77.Ronald plans to conduct a research on the use of a new C. Florence Nightingale method of pain assessment scale. Which of the following is D. Jean Watson the second step in the conceptualizing phase of the 84.Ms. Garcia is responsible to the number of personnel research process? reporting to her. This principle refers to: A. Formulating the research hypothesis A. Span of control B. Review related literature B. Unity of command C. Formulating and delimiting the research C. Downward communication problem D. Leader D. Design the theoretical and conceptual 85.Ensuring that there is an informed consent on the part framework of the patient before a surgery is done, illustrates the 78. The leader of the study knows that certain patients who bioethical principle of: are in a specialized research setting tend to respond psychologically to the conditions of the study. This referred A. Beneficence to as : B. Autonomy C. Veracity A. Cause and effect D. Non-maleficence B. Hawthorne effect 86.Nurse Reese is teaching a female client with peripheral C. Halo effect vascular disease about foot care; Nurse Reese should D. Horns effect include which instruction? 79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct? A. Avoid wearing cotton socks. B. Avoid using a nail clipper to cut toenails. A. Plans to include whoever is there during his C. Avoid wearing canvas shoes. study. D. Avoid using cornstarch on feet. B. Determines the different nationality of 87.A client is admitted with multiple pressure ulcers. When patients frequently admitted and decides to developing the client’s diet plan, the nurse should include: get representations samples from each. C. Assigns numbers for each of the patients, A. Fresh orange slices place these in a fishbowl and draw 10 from B. Steamed broccoli it. C. Ice cream D. Decides to get 20 samples from the admitted D. Ground beef patties patients 88.The nurse prepares to administer a cleansing enema. 80. The nursing theorist who developed transcultural What is the most common client position used for this nursing theory is: procedure? A. Florence Nightingale A. Lithotomy B. Madeleine Leininger B. Supine C. Albert Moore C. Prone D. Sr. Callista Roy D. Sims’ left lateral 81.Marion is aware that the sampling method that gives 89.Nurse Marian is preparing to administer a blood equal chance to all units in the population to get picked is: transfusion. Which action should the nurse take first? A. Random A. Arrange for typing and cross matching of the B. Accidental client’s blood. C. Quota B. Compare the client’s identification wristband D. Judgment with the tag on the unit of blood.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE C. Start an I.V. infusion of normal saline D. Roll the vial gently between the palms. solution. 96.Which intervention should the nurse Trish use when D. Measure the client’s vital signs. administering oxygen by face mask to a female client? 90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. A. Secure the elastic band tightly around the Which type of nursing intervention is required? client’s head. B. Assist the client to the semi-Fowler position A. Independent if possible. B. Dependent C. Apply the face mask from the client’s chin up C. Interdependent over the nose. D. Intradependent D. Loosen the connectors between the oxygen 91.A female client is to be discharged from an acute care equipment and humidifier. facility after treatment for right leg thrombophlebitis. The 97.The maximum transfusion time for a unit of packed red Nurse Betty notes that the client’s leg is pain-free, without blood cells (RBCs) is: redness or edema. The nurse’s actions reflect which step of the nursing process? A. 6 hours B. 4 hours A. Assessment C. 3 hours B. Diagnosis D. 2 hours C. Implementation 98.Nurse Monique is monitoring the effectiveness of a D. Evaluation client’s drug therapy. When should the nurse Monique 92.Nursing care for a female client includes removing obtain a blood sample to measure the trough drug level? elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention? A. 1 hour before administering the next dose. B. Immediately before administering the next A. To increase blood flow to the heart dose. B. To observe the lower extremities C. Immediately after administering the next C. To allow the leg muscles to stretch and relax dose. D. To permit veins in the legs to fill with blood. D. 30 minutes after administering the next 93.Which nursing intervention takes highest priority when dose. caring for a newly admitted client who’s receiving a blood 99.Nurse May is aware that the main advantage of using a transfusion? floor stock system is: A. Instructing the client to report any itching, A. The nurse can implement medication orders swelling, or dyspnea. quickly. B. Informing the client that the transfusion B. The nurse receives input from the usually take 1 ½ to 2 hours. pharmacist. C. Documenting blood administration in the C. The system minimizes transcription errors. client care record. D. The system reinforces accurate calculations. D. Assessing the client’s vital signs when the 100. Nurse Oliver is assessing a client’s abdomen. Which transfusion ends. finding should the nurse report as abnormal? 94.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is A. Dullness over the liver. most appropriate for this problem? B. Bowel sounds occurring every 10 seconds. C. Shifting dullness over the abdomen. A. Give the feedings at room temperature. D. Vascular sounds heard over the renal B. Decrease the rate of feedings and the arteries. concentration of the formula. C. Place the client in semi-Fowler’s position while feeding. D. Change the feeding container every 12 hours. 95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should: A. Do nothing. B. Invert the vial and let it stand for 3 to 5 minutes. C. Shake the vial vigorously.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE ANSWER KEY 9. Answer: (A) “My ankle looks less swollen now”. Ice application decreases pain and 1. Answer: (D) The actions of a reasonably swelling. Continued or increased pain, prudent nurse with similar education and redness, and increased warmth are signs of experience. The standard of care is inflammation that shouldn’t occur after ice determined by the average degree of skill, application care, and diligence by nurses in similar 10. Answer: (B) Hyperkalemia. A loop diuretic circumstances. removes water and, along with it, sodium 2. Answer: (B) I.M. With a platelet count of and potassium. This may result in 22,000/μl, the clients tends to bleed easily. hypokalemia, hypovolemia, Therefore, the nurse should avoid using the and hyponatremia. I.M. route because the area is a highly 11. Answer:(A) Have condescending trust and vascular and can bleed readily when confidence in penetrated by a needle. The bleeding can be their subordinates. Benevolent-authoritative difficult to stop. managers pretentiously show their trust and 3. Answer: (C) “Digoxin 0.125 mg P.O. once confidence to their followers. daily” The nurse should always place a zero 12. Answer: (A) Provides continuous, before a decimal point so that no one coordinated and comprehensive nursing misreads the figure, which could result in a services. Functional nursing is focused on dosage error. The nurse should never insert tasks and activities and not on the care of the a zero at the end of a dosage that includes a patients. decimal point because this could be misread, 13. Answer: (B) Standard written order. This is a possibly leading to a tenfold increase in the standard written order. Prescribers write a dosage. single order for medications given only once. 4. Answer: (A) Ineffective peripheral tissue A stat order is written for medications given perfusion related to immediately for an urgent client problem. A venous congestion. Ineffective peripheral standing order, also known as a protocol, tissue perfusion related to establishes guidelines for treating venous congestion takes the highest priority a particular disease or set of symptoms in because venous inflammation and clot special care areas such as the coronary care formation impede blood flow in a client with unit. Facilities also may institute medication deep vein thrombosis. protocols that specifically designate drugs 5. Answer: (B) A 44 year-old myocardial that a nurse may not give. infarction (MI) client who is complaining of 14. Answer: (D) Liquid or semi-liquid nausea. Nausea is a symptom of impending stools. Passage of liquid or semi-liquid stools myocardial infarction (MI) and should be results from seepage of unformed bowel assessed immediately so that treatment can contents around the impacted stool in the be instituted and further damage to the rectum. Clients with fecal impaction don’t heart is avoided. pass hard, brown, formed stools because 6. Answer: (C) Check circulation every 15-30 the feces can’t move past the impaction. minutes. Restraints encircle the limbs, which These clients typically report the urge to place the client at risk for circulation being defecate (although they can’t pass stool) and restricted to the distal areas of the a decreased appetite. extremities. Checking the client’s circulation 15. Answer: (C) Pulling the helix up and back. To every 15-30 minutes will allow the nurse to perform an otoscopic examination on an adjust the restraints before injury from adult, the nurse grasps the helix of the ear decreased blood flow occurs. and pulls it up and back to straighten the 7. Answer: (A) Prevent stress ulcer. Curling’s ear canal. For a child, the nurse grasps the ulcer occurs as a generalized stress response helix and pulls it down to straighten the ear in burn patients. This results in a decreased canal. Pulling the lobule in any direction production of mucus and increased secretion wouldn’t straighten the ear canal for of gastric acid. The best treatment for this visualization. prophylactic use of antacids and H2 receptor 16. Answer: (A) Protect the irritated skin from blockers. sunlight. Irradiated skin is very sensitive and 8. Answer: (D) Continue to monitor and record must be protected with clothing or sunblock. hourly urine output. Normal urine output for The priority approach is the avoidance of an adult is approximately 1 ml/minute (60 strong sunlight. ml/hour). Therefore, this client’s output is 17. Answer: (C) Assist the client in removing normal. Beyond continued evaluation, no dentures and nail polish. Dentures, hairpins, nursing action is warranted. and combs must be removed. Nail polish  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE must be removed so that cyanosis can be 29. Answer: (A) BP – 80/60, Pulse – 110 easily monitored by observing the nail beds. irregular. The classic signs of cardiogenic 18. Answer: (D) Sudden onset of continuous shock are low blood pressure, rapid and epigastric and back pain. The autodigestion weak irregular pulse, cold, clammy skin, of tissue by the pancreatic enzymes results in decreased urinary output, and cerebral pain from inflammation, edema, and possible hypoxia. hemorrhage. Continuous, unrelieved 30. Answer: (A) Take the proper equipment, epigastric or back pain reflects the place the client in a comfortable position, inflammatory process in the pancreas. and record the appropriate information in 19. Answer: (B) Provide high-protein, high- the client’s chart. It is a general or carbohydrate diet. A positive nitrogen comprehensive statement about the correct balance is important for meeting metabolic procedure, and it includes the basic ideas needs, tissue repair, and resistance to which are found in the other options infection. Caloric goals may be as high as 31. Answer: (B) Evaluation. Evaluation includes 5000 calories per day. observing the person, asking questions, and 20. Answer: (A) Blood pressure and pulse comparing the patient’s behavioral rate. The baseline must be established to responses with the expected outcomes. recognize the signs of an anaphylactic or 32. Answer: (C) History of present illness. The hemolytic reaction to the transfusion. history of present illness is the single most 21. Answer: (D) Immobilize the leg before important factor in assisting the health moving the client. If the nurse suspects a professional in arriving at a diagnosis or fracture, splinting the area before moving determining the person’s needs. the client is imperative. The nurse should call 33. Answer: (A) Trochanter roll extending from for emergency help if the client is not the crest of the ileum to the mid-thigh. A hospitalized and call for a physician for the trochanter roll, properly placed, provides hospitalized client. resistance to the external rotation of the hip. 22. Answer: (B) Admit the client into a private 34. Answer: (C) Stage III. Clinically, a deep crater room. The client who has a radiation implant or without undermining of adjacent tissue is is placed in a private room and has a limited noted. number of visitors. This reduces the 35. Answer: (A) Second intention healing. When exposure of others to the radiation. wounds dehisce, they will allowed to heal by 23. Answer: (C) Risk for secondary intention infection. Agranulocytosis is characterized by 36. Answer: (D) Tachycardia. With an a reduced number of leukocytes (leucopenia) extracellular fluid or plasma volume deficit, and neutrophils (neutropenia) in the blood. compensatory mechanisms stimulate the The client is at high risk for infection because heart, causing an increase in heart rate. of the decreased body defenses against 37. Answer: (A) 0.75. To determine the number microorganisms. Deficient knowledge related of milliliters the client should receive, the to the nature of the disorder may be nurse uses the fraction method in the appropriate diagnosis but is not the priority. following equation. 24. Answer: (B) Place the client on the left side in  75 mg/X ml = 100 mg/1 ml the Trendelenburg position. Lying on the left  To solve for X, cross-multiply: side may prevent air from flowing into the  75 mg x 1 ml = X pulmonary veins. The Trendelenburg position ml x 100 mg increases intrathoracic pressure, which  75 = 100X decreases the amount of blood pulled into  75/100 = X the vena cava during aspiration.  0.75 ml (or ¾ 25. Answer: (A) Autocratic. The autocratic style ml) = X of leadership is a task-oriented and directive. 38. Answer: (D) It’s a measure of effect, not a 26. Answer: (D) 2.5 cc. 2.5 cc is to be added, standard measure of weight or quantity. An because only a 500 cc bag of solution is being insulin unit is a measure of effect, not a medicated instead of a 1 liter. standard measure of weight or quantity. 27. Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. Different drugs measured in units may have The child is to receive 400 cc over a period of no relationship to one another in quality or 8 hours = 50 cc/hr. quantity. 28. Answer: (B) Assess the client for presence of 39. Answer: (B) 38.9 °C. To convert Fahrenheit pain. Assessing the client for pain is a very degreed to Centigrade, use this formula important measure. Postoperative pain is an  °C = (°F – 32) ÷ 1.8 indication of complication. The nurse should  °C = (102 – 32) ÷ 1.8 also assess the client for pain to provide for  °C = 70 ÷ 1.8 the client’s comfort.  °C = 38.9  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE 40. Answer: (C) Failing eyesight, especially close The fingertips and finger pads best vision. Failing eyesight, especially close distinguish texture and shape. The dorsal vision, is one of the first signs of aging in surface best feels warmth. middle life (ages 46 to 64). More frequent 47. Answer: (C) Formative. Formative (or aches and pains begin in the early late years concurrent) evaluation occurs continuously (ages 65 to 79). Increase in loss of muscle throughout the teaching and learning tone occurs in later years (age 80 and older). process. One benefit is that the nurse can 41. Answer: (A) Checking and taping all adjust teaching strategies as necessary to connections. Air leaks commonly occur if the enhance learning. Summative, or system isn’t secure. Checking all connections retrospective, evaluation occurs at the and taping them will prevent air leaks. The conclusion of the teaching and learning chest drainage system is kept lower to session. Informative is not a type of promote drainage – not to prevent leaks. evaluation. 42. Answer: (A) Check the client’s identification 48. Answer: (B) Once per year. Yearly band. Checking the client’s identification mammograms should begin at age 40 and band is the safest way to verify a client’s continue for as long as the woman is in good identity because the band is assigned on health. If health risks, such as family history, admission and isn’t be removed at any time. genetic tendency, or past breast cancer, (If it is removed, it must be replaced). Asking exist, more frequent examinations may be the client’s name or having the client necessary. repeated his name would be appropriate 49. Answer: (A) Respiratory acidosis. The client only for a client who’s alert, oriented, and has a below-normal (acidic) blood pH value able to understand what is being said, but and an above-normal partial pressure of isn’t the safe standard of practice. Names on arterial carbon dioxide (Paco2) value, bed aren’t always reliable indicating respiratory acidosis. In respiratory 43. Answer: (B) 32 drops/minute. Giving 1,000 alkalosis, the pH value is above normal and in ml over 8 hours is the same as giving 125 ml the Paco2 value is below normal. In over 1 hour (60 minutes). Find the number of metabolic acidosis, the pH and bicarbonate milliliters per minute as follows: (Hco3) values are below normal. In metabolic  125/60 minutes = X/1 minute alkalosis, the pH and Hco3 values are above  60X = 125 = 2.1 ml/minute normal.  To find the number of drops 50. Answer: (B) To provide support for the client per minute: and family in coping with terminal  2.1 ml/X gtt = 1 illness. Hospices provide supportive care for ml/ 15 gtt terminally ill clients and their families.  X = 32 Hospice care doesn’t focus on counseling gtt/minute, or regarding health care costs. Most client 32 referred to hospices have been treated for drops/minute their disease without success and will receive 44. Answer: (A) Clamp the catheter. If a central only palliative care in the hospice. venous catheter becomes disconnected, the 51. Answer: (C) Using normal saline solution to nurse should immediately apply a catheter clean the ulcer and applying a protective clamp, if available. If a clamp isn’t available, dressing as necessary. Washing the area with the nurse can place a sterile syringe or normal saline solution and applying a catheter plug in the catheter hub. After protective dressing are within the nurse’s cleaning the hub with alcohol or povidone- realm of interventions and will protect the iodine solution, the nurse must replace the area. Using a povidone-iodine wash and an I.V. extension and restart the infusion. antibiotic cream require a physician’s order. 45. Answer: (D) Auscultation, percussion, and Massaging with an astringent can further palpation.The correct order of assessment damage the skin. for examining the abdomen is inspection, 52. Answer: (D) Foot. An elastic bandage should auscultation, percussion, and palpation. The be applied form the distal area to the reason for this approach is that the less proximal area. This method promotes venous intrusive techniques should be performed return. In this case, the nurse should begin before the more intrusive techniques. applying the bandage at the client’s foot. Percussion and palpation can alter natural Beginning at the ankle, lower thigh, or knee findings during auscultation. does not promote venous return. 46. Answer: (D) Ulnar surface of the hand. The 53. Answer: (B) Hypokalemia. Insulin nurse uses the ulnar surface, or ball, of the administration causes glucose and potassium hand to asses tactile fremitus, thrills, and to move into the cells, causing hypokalemia. vocal vibrations through the chest wall.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE 54. Answer: (A) Throbbing headache or contaminated and the results of the test dizziness. Headache and dizziness often would be invalid. occur when nitroglycerin is taken at the 61. Answer: (A) Puts all the four points of the beginning of therapy. However, the client walker flat on the floor, puts weight on the usually develops tolerance hand pieces, and then walks into it. When 55. Answer: (D) Check the client’s level of the client uses a walker, the nurse stands consciousness. Determining adjacent to the affected side. The client is unresponsiveness is the first step assessment instructed to put all four points of the walker action to take. When a client is in ventricular 2 feet forward flat on the floor before tachycardia, there is a significant decrease in putting weight on hand pieces. This will cardiac output. However, checking the ensure client safety and prevent stress cracks unresponsiveness ensures whether the client in the walker. The client is then instructed to is affected by the decreased cardiac output. move the walker forward and walk into it. 56. Answer: (B) On the affected side of the 62. Answer: (C) Draws one line to cross out the client.When walking with clients, the nurse incorrect information and then initials the should stand on the affected side and grasp change. To correct an error documented in a the security belt in the midspine area of the medical record, the nurse draws one line small of the back. The nurse should position through the incorrect information and then the free hand at the shoulder area so that initials the error. An error is never erased the client can be pulled toward the nurse in and correction fluid is never used in the the event that there is a forward fall. The medical record. client is instructed to look up and outward 63. Answer: (C) Secures the client safety belts rather than at his or her feet. after transferring to the stretcher. During the 57. Answer: (A) Urine output: 45 transfer of the client after the surgical ml/hr. Adequate perfusion must be procedure is complete, the nurse should maintained to all vital organs in order for the avoid exposure of the client because of the client to remain visible as an organ donor. A risk for potential heat loss. Hurried urine output of 45 ml per hour indicates movements and rapid changes in the adequate renal perfusion. Low blood position should be avoided because these pressure and delayed capillary refill time are predispose the client to hypotension. At the circulatory system indicators of inadequate time of the transfer from the surgery table to perfusion. A serum pH of 7.32 is acidotic, the stretcher, the client is still affected by the which adversely affects all body tissues. effects of the anesthesia; therefore, the 58. Answer: (D ) Obtaining the specimen from client should not move self. Safety belts can the urinary drainage bag. A urine specimen is prevent the client from falling off the not taken from the urinary drainage bag. stretcher. Urine undergoes chemical changes while 64. Answer: (B) Gown and gloves. Contact sitting in the bag and does not necessarily precautions require the use of gloves and a reflect the current client status. In addition, gown if direct client contact is anticipated. it may become contaminated with bacteria Goggles are not necessary unless the nurse from opening the system. anticipates the splashes of blood, body 59. Answer: (B) Cover the client, place the call fluids, secretions, or excretions may occur. light within reach, and answer the phone Shoe protectors are not necessary. call. Because telephone call is an emergency, 65. Answer: (C) Quad cane. Crutches and a the nurse may need to answer it. The other walker can be difficult to maneuver for a appropriate action is to ask another nurse to client with weakness on one side. A cane is accept the call. However, is not one of the better suited for client with weakness of the options. To maintain privacy and safety, the arm and leg on one side. However, the quad nurse covers the client and places the call cane would provide the most stability light within the client’s reach. Additionally, because of the structure of the cane and the client’s door should be closed or the because a quad cane has four legs. room curtains pulled around the bathing 66. Answer: (D) Left side-lying with the head of area. the bed elevated 45 degrees. To facilitate 60. Answer: (C) Use a sterile plastic container for removal of fluid from the chest wall, the obtaining the specimen. Sputum specimens client is positioned sitting at the edge of the for culture and sensitivity testing need to be bed leaning over the bedside table with the obtained using sterile techniques because feet supported on a stool. If the client is the test is done to determine the presence of unable to sit up, the client is positioned lying organisms. If the procedure for obtaining the in bed on the unaffected side with the head specimen is not sterile, then the specimen is of the bed elevated 30 to 45 degrees. not sterile, then the specimen would be  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE 67. Answer: (D) Reliability Reliability is of what has been done on the study by consistency of the research instrument. It previous researchers. refers to the repeatability of the instrument 78. Answer: (B) Hawthorne effect. Hawthorne in extracting the same responses upon its effect is based on the study of Elton Mayo repeated administration. and company about the effect of an 68. Answer: (A) Keep the identities of the subject intervention done to improve the working secret. Keeping the identities of the research conditions of the workers on their subject secret will ensure anonymity because productivity. It resulted to an increased this will hinder providing link between the productivity but not due to the intervention information given to whoever is its source. but due to the psychological effects of being 69. Answer: (A) Descriptive- observed. They performed differently correlational. Descriptive- correlational study because they were under observation. is the most appropriate for this study 79. Answer: (B) Determines the different because it studies the variables that could be nationality of patients frequently admitted the antecedents of the increased incidence and decides to get representations samples of nosocomial infection. from each. Judgment sampling involves 70. Answer: (C) Use of laboratory data. Incidence including samples according to the of nosocomial infection is best collected knowledge of the investigator about the through the use of biophysiologic measures, participants in the study. particularly in vitro measurements, hence 80. Answer: (B) Madeleine Leininger. Madeleine laboratory data is essential. Leininger developed the theory on 71. Answer: (B) Quasi-experiment. Quasi- transcultural theory based on her experiment is done when randomization and observations on the behavior of selected control of the variables are not possible. people within a culture. 72. Answer: (C) Primary source. This refers to a 81. Answer: (A) Random. Random sampling gives primary source which is a direct account of equal chance for all the elements in the the investigation done by the investigator. In population to be picked as part of the contrast to this is a secondary source, which sample. is written by someone other than the original 82. Answer: (A) Degree of agreement and researcher. disagreement. Likert scale is a 5-point 73. Answer: (A) Non-maleficence. Non- summated scale used to determine the maleficence means do not cause harm or do degree of agreement or disagreement of the any action that will cause any harm to the respondents to a statement in a study patient/client. To do good is referred as 83. Answer: (B) Sr. Callista Roy. Sr. Callista Roy beneficence. developed the Adaptation Model which 74. Answer: (C) Res ipsa loquitor. Res ipsa involves the physiologic mode, self-concept loquitor literally means the thing speaks for mode, role function mode and dependence itself. This means in operational terms that mode. the injury caused is the proof that there was 84. Answer: (A) Span of control. Span of control a negligent act. refers to the number of workers who report 75. Answer: (B) The Board can investigate directly to a manager. violations of the nursing law and code of 85. Answer: (B) Autonomy. Informed consent ethics. Quasi-judicial power means that the means that the patient fully understands Board of Nursing has the authority to about the surgery, including the risks investigate violations of the nursing law and involved and the alternative solutions. In can issue summons, subpoena or subpoena giving consent it is done with full knowledge duces tecum as needed. and is given freely. The action of allowing the 76. Answer: (C) May apply for re-issuance of patient to decide whether a surgery is to be his/her license based on certain conditions done or not exemplifies the bioethical stipulated in RA 9173. RA 9173 sec. 24 states principle of autonomy. that for equity and justice, a revoked license 86. Answer: (C) Avoid wearing canvas shoes. The maybe re-issued provided that the following client should be instructed to avoid wearing conditions are met: a) the cause for canvas shoes. Canvas shoes cause the feet to revocation of license has already been perspire, which may, in turn, cause corrected or removed; and, b) at least four skin irritation and breakdown. Both cotton years has elapsed since the license has been and cornstarch absorb perspiration. The revoked. client should be instructed to cut toenails 77. Answer: (B) Review related literature. After straight across with nail clippers. formulating and delimiting the research 87. Answer: (D) Ground beef patties. Meat is an problem, the researcher conducts a review excellent source of complete protein, which of related literature to determine the extent this client needs to repair the tissue  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE breakdown caused by pressure symptoms of life-threatening allergic ulcers. Oranges and broccoli supply vitamin C reactions include itching, swelling, and but not protein. Ice cream supplies only dyspnea. Although the nurse should inform some incomplete protein, making it less the client of the duration of the transfusion helpful in tissue repair. and should document its administration, 88. Answer: (D) Sims’ left lateral. The Sims’ left these actions are less critical to the client’s lateral position is the most common position immediate health. The nurse should assess used to administer a cleansing enema vital signs at least hourly during the because it allows gravity to aid the flow of transfusion. fluid along the curve of the sigmoid colon. If 94. Answer: (B) Decrease the rate of feedings the client can’t assume this position nor has and the concentration of the poor sphincter control, the dorsal recumbent formula. Complaints of abdominal or right lateral position may be used. The discomfort and nausea are common in supine and prone positions are inappropriate clients receiving tube feedings. Decreasing and uncomfortable for the client. the rate of the feeding and the concentration 89. Answer: (A) Arrange for typing and cross of the formula should decrease the client’s matching of the client’s blood. The nurse first discomfort. Feedings are normally given at arranges for typing and cross matching of the room temperature to minimize abdominal client’s blood to ensure compatibility with cramping. To prevent aspiration during donor blood. The other options,although feeding, the head of the client’s bed should appropriate when preparing to administer a be elevated at least 30 degrees. Also, to blood transfusion, come later. prevent bacterial growth, feeding containers 90. Answer: (A) Independent. Nursing should be routinely changed every 8 to 12 interventions are classified as independent, hours. interdependent, or dependent. Altering the 95. Answer: (D) Roll the vial gently between the drug schedule to coincide with the client’s palms. Rolling the vial gently between the daily routine represents an independent palms produces heat, which helps dissolve intervention, whereas consulting with the the medication. Doing nothing or inverting physician and pharmacist to change a client’s the vial wouldn’t help dissolve the medication because of adverse reactions medication. Shaking the vial vigorously could represents an interdependent intervention. cause the medication to break down, altering Administering an already-prescribed drug on its action. time is a dependent intervention. An 96. Answer: (B) Assist the client to the semi- intradependent nursing intervention doesn’t Fowler position if possible. By assisting the exist. client to the semi-Fowler position, the nurse 91. Answer: (D) Evaluation. The nursing actions promotes easier chest expansion, breathing, described constitute evaluation of the and oxygen intake. The nurse should secure expected outcomes. The findings show that the elastic band so that the face mask fits the expected outcomes have been achieved. comfortably and snugly rather than tightly, Assessment consists of the client’s history, which could lead to irritation. The nurse physical examination, and laboratory studies. should apply the face mask from the client’s Analysis consists of considering assessment nose down to the chin — not vice versa. The information to derive the appropriate nurse should check the connectors between nursing diagnosis. Implementation is the the oxygen equipment and humidifier to phase of the nursing process where the ensure that they’re airtight; loosened nurse puts the plan of care into action. connectors can cause loss of oxygen. 92. Answer: (B) To observe the lower 97. Answer: (B) 4 hours. A unit of packed RBCs extremities. Elastic stockings are used to may be given over a period of between 1 and promote venous return. The nurse needs to 4 hours. It shouldn’t infuse for longer than 4 remove them once per day to observe the hours because the risk of contamination and condition of the skin underneath the sepsis increases after that time. Discard or stockings. Applying the stockings increases return to the blood bank any blood not given blood flow to the heart. When the stockings within this time, according to facility policy. are in place, the leg muscles can still stretch 98. Answer: (B) Immediately before and relax, and the veins can fill with blood. administering the next dose. Measuring the 93. Answer:(A) Instructing the client to report blood drug concentration helps determine any itching, swelling, or dyspnea. Because whether the dosing has achieved the administration of blood or blood products therapeutic goal. For measurement of the may cause serious adverse effects such as trough, or lowest, blood level of a drug, the allergic reactions, the nurse must monitor nurse draws a blood sample immediately the client for these effects. Signs and before administering the next dose.  PNLE 1 FOR FOUNDATION OF PROFESSIONAL NURSING PRACTICE Depending on the drug’s duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose. 99. Answer: (A) The nurse can implement medication orders quickly. A floor stock system enables the nurse to implement medication orders quickly. It doesn’t allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations. 100. Answer: (C) Shifting dullness over the abdomen. Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.