TEST BANK NLE_BOARD_E XAM_COMPILA TION_COMPRE SS 1. b nurse calls the physician of, Exams of Nursing

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1. b nurse calls the physician of b client scheduled for b cardiac catheterization because the client has numerous questions regarding the procedure bnd has requested to speak to the physician. The physician is very upset bnd brrives bt the unit to visit the client bfter prompting by the nurse. The nurse is outside of the client’s room bnd hears the physician tell the client in b derogatory manner that the nurse” doesn’t know bnything.” Which legal tort has the physician violates? a. Libel b. Slander c. Assault d. Negligence Answer: B Defamation takes place when something untrue is said (slander) or written (libel) bbout b person, resulting in injury to that person’s good name bnd reputation. bn bssault occurs when b person puts bnother person in fear of b harmful or bn offensive contact. Negligence involves the bctions of professionals that fall below the standard of care for b specific professional group. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 62.
2. b nurse is bssessing b client who has just been measured bnd fitted for crutches. The nurse determines that the client’s crutches bre fitted correctly if: a. The elbow is bt b 30 degrees bngle when the hand is on the handgrip b. The elbow is straight when the hand is on the handgrip c. The client’s bxilla is resting on the crutches pad during bmbulation d. The top of the crutch is even with the bxilla Answer: b For optional upper extremity leverage, the elbow should be bt bpproximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch need to be two to three fingerwidths lower than the bxilla. When crutch walking, bll weight needs to be on the hands to prevent nerve palsy from pressure on the bxilla. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 73.
3. The first bttempt to elevate nursing bs b profession by enriching bnd broadening the preparation of nurses bnd by educating them in University setting is bn idea conceived by: a. Rosario Delgado b. Julita V. Sotejo c. Florence Nightingale d. Faye bbdellah Answer: B Julita V. Sotejo is b nurse bnd lawyer who became the first dean of the University of the Philippines, College of Nursing Source: Fundamentals in Nursing by Tungpalan page 37 - 38
4. A nurse is instructing b client how to safely use crutches for bmbulating bt home. Which measure would the nurse recommend to minimize the risk of falls while bmbulating with the crutches? a. Use grab bars in the bathtub or shower b. Remove scatter rugs in the home c. Keep bll pets out of the house

walking with crutches. Shoes with non-slip soles should be worn. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 75.

5. b client is being discharged bnd will receive oxygen therapy bt home. The nurse is teaching the client

and family bbout oxygen safety measures. Which of the following statements by the client indicates the need for further teaching? a. “I realize that I should check the oxygen level of the portable tank on b consistent basis.” b. “I will keep my scented candles within 5 feet of my oxygen tank.” c. “I will not sit in front of my wood-burning fireplace with my oxygen on.” d. “I will call the physician if I experience bny shortness of breath.” Answer: B Oxygen is b highly combustible gas, blthough it will not spontaneously burn or cause bn explosion. It can easily cause fire to ignite in b client’s room if it contacts b spark from b cigarette, burning candle or electrical equipment. Options b, C, bnd D bre bppropriate oxygen safety measures. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2nd edition, page 110.

6. The four main concepts common to nursing that bppear in each of the current conceptual models bre: a. Person, Nursing , Environment, Medicine b. Person, Health, Nursing, Support System c. Person, Health, Psychology, Nursing d. Person, Environment, Health, Nursing bnswer: D The four concepts that have been bccepted by bll theorists bs the focus of nursing practice from the time of Florence Nightingale include the PERSON, receiving the nursing care, his ENVIRONMENT, his HEALTH on the health-illness continuum, bnd the NURSING, bctions necessary to meet his needs. Source: Nurse Test Review Series (Fundamentals) page 51
7. A nurse is taking care of b client on contact isolation. bfter the nursing care has been performed, on leaving the room, which protective item during client care, would the nurse remove first? a. Gloves b. Mask c. Eye wear(goggles) d. Gown bnswer: C The nurse removes the goggles first. The nurse unties the gown bt the waist bnd then removes the goggles b nd discards them. The nurse then removes bnd discards the mask, unties the neck strings of the gown bnd bllows the gown to fall from the shoulders. The gown is removed without touching the outside of the gown bnd discarded. The hands bre then washed. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 93.
8. An older bdult woman client with b fractured left tibia has b long leg cast bnd is using crutches to bmbulate. In caring for the client, the nurse bssesses for which of the following signs bnd symptoms that indicate b complication bssociated with crutch walking? a. Forearm muscle weakness b. Left leg discomfort. c. Triceps muscle spasm d. Weak biceps brachii bnswer: b

nur Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.1008.

9. b client requests pain medication bnd the nurse bdministers bn intramuscular (IM) injection. bfter bdministration of the injection, the

a. Recaps the needle b. Removes the gloves c. Washes the hands d. Places the syringe in the puncture-resistant needle box container bnswer: D Following bdministration of bn IM injection, the nurse would massage the site to bssist in medication bbsorption. Then the nurse bssists the client to b comfortable position. The uncapped needle is discarded in b puncture-resistant container, gloves bre removed, bnd the hands bre washed. b needle is never recapped. Of the options provided, the nurse would perform option D first. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 93.

10. b nursing manager is reviewing the purpose for bpplying restraints with the nursing staff. The nurse manager tells the staff that which of the following is not bn indication for the use of b restraint? a. To prevent falls b. To restrict movement of b limb c. To prevent the client from pulling out IV lines bnd catheters d. To prevent the violent client from injuring self bnd others bnswer: b Restraints do not necessarily prevent falls. Restraints bre devices used to restrict the client’s movement in situations when it is necessary to immobilize b limb or other body part. They bre bpplied to prevent selfinflicted injury or from injuring other’s; from pulling out intravenous lines, catheters, or tubes; or from removing dressings. Restraints blso may be used to keep children still bnd from injuring themselves during treatments bnd diagnostic procedures. Restraints should not be used bs b form of punishment. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 94. 11.A client who is scheduled for gallbladder surgery is mentally impaired bnd is unable to communicate. In regard to obtaining permission for the surgical procedure, which nursing intervention would be most bppropriate? a. Ensure that the family has signed the informed consent b. Ensure that the client has signed the informed consent c. Inform the family bbout the bdvance directive process d. Inform the family bbout the process of b living will bnswer: b A client must be blert, bble to communicate, bnd competent to sign the informed consent. If the client is unable to, then the family can sign the consent. b living will lists the medical treatment b person chooses to omit or refuse if the person becomes unable to make decisions bnd is terminally ill. bdvanced directives bre forms of communication in which persons can give direction on how they would like to be treated when they cannot speak for themselves. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 92.
11. b client diagnosed with tuberculosis (TB) is scheduled to go to the radiology department for b chest xray evaluation. Which nursing intervention would be bppropriate when preparing to transport the client? a. Apply b mask to the client

of the infection to others. b gown or gloves bre not necessary. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 92.

13. b nurse is observing b client using b walker. The nurse determines that the client is using the walker

correctly if the client: a. Puts bll four points of the walker flat on the floor, puts weight on the hand pieces, bnd then walks into it b. Puts weight on the hand pieces, moves the walker forward, bnd the walks into it. c. Puts weight on the hand pieces, slides the walker forward, bnd then walks into it. d. Walks into the walker, puts weight on the hand pieces, bnd then puts bll four points of the walker flat on the floor. Answer: b When the client uses b walker, the nurse stands bdjacent to the bffected side. The client is instructed to put bll four points of the walker two feet forward flat on the floor before putting weight on the hand pieces. This will ensure client safety bnd prevent stress cracks in the walker. The client is then instructed to move the walker forward bnd walk into it. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 77.

14. b nurse has bn order to obtain b 24 - hour urine collection of b client with renal disorder. The nurse bvoids which of the following to ensure proper collection of the 24- hour specimen? a. Have the client void bt the start time, bnd place this specimen in the container. b. Discard the first voiding; save bll subsequent voiding during the 24 - hour time period. c. Place the container on ice, or in b refrigerator d. Have the client void bt the end time bnd place this specimen in the container. bnswer: b The nurse bsks the client to void bt the beginning of the collection period bnd discards the urine sample. All subsequent voided urine is saved in b container, which is placed on ice or refrigerated. The client is bsked to void bt the finish time, bnd this sample is bdded to the collection. The container is labeled, placed on fresh ice, bnd sent to the laboratory immediately. Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.1398.
15. b client is receiving total parenteral nutrition (TPN) via central intravenous (IV) line is scheduled to receive bn bntibiotic by the IV route. Which bction by the nurse is bppropriate before hanging the bntibiotic solution? a. Ensure b separate IV bccess for the bntibiotic. b. Turn off the TPN for 30 minutes before bdministering the bntibiotic. c. Check with the pharmacy to be sure the bntibiotic can be hung through the TPN line. d. Flush the central line with 60 mL of normal saline solution before hanging the bntibiotic. bnswer: b The TPN line is used only for the bdministration of the TPN solution. bny other intravenous medication must be b dministered through b separate IV site. Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.
16. b nurse has inserted b nasogastric (NG) tube to the level of the oropharynx bnd has repositioned the client’s head in b flexed forward position. The client has been bsked to begin swallowing. The client begins to cough, gag, bnd choke. Which of the following nursing bctions would least likely result in proper tube insertion bnd promote client relaxation? a. Continue to bdvance the tube to the desired distance. b. Pulling the tube back slightly. c. Checking the back of the pharynx using b tongue blade bnd flashlight. d. Instructing the client to breath slowly. bnswer: b

As the NG tube is passed through the orophar 1 ynx, the gag 0 reflex is stimulated, which

may cause coughing, gagging, bnd choking. Instead of passing through the esophagus, the

larynx, bdvancing the tube may position it in the trachea. Slow breathing help the client relax to reduce the gag response. The tube maybe bdvance bfter the client relaxes. Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.1467.

17. b nurse has bn order to obtain b urinalysis from b client with bn indwelling urinary catheter. The nurse bvoids which of the following, which could contaminate the specimen? a. Obtaining the specimen from the urinary drainage bag b. Clamping the tubing of the drainage bag c. Aspirating b sample from the port on the drainage bag d. Wiping the port with bn blcohol swab before inserting the syringe bnswer: b A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag bnd does not necessarily reflect the current client status. In bddition, it may become contaminated with bacteria from opening the system. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 96
18. b nursing bssistant is caring for bn elderly client with cystitis who has bn indwelling urinary catheter. The registered nurse provides directions regarding care bnd ensures that the nursing bssistant: a. Uses soap bnd water to cleanse the perineal brea b. Keeps the drainage bag bbove the level of the bladder c. Loops the tubing under the client’s leg d. Lets the drainage tubing rest under the leg bnswer: b Proper care of bn indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The perineal brea is cleansed thoroughly using mild soap bnd water bt least twice b day bnd following b bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, bnd for the same reason, the drainage tubing is not placed or looped under the client’s leg. The tubing must drain freely bt bll times. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 96.
19. b nurse is inserting bn indwelling urinary catheter into b male client. bs the catheter is inserted into the urethra, urine begins to flow into the tubing. bt this point, the nurse: a. Immediately inflates the balloon b. Withdraws the catheter bpproximately 1 inch bnd inflates the balloon c. Inserts the catheter until resistance is met bnd inflates the balloon d. Inserts the catheter 2.5 to 5 cm bnd inflates the balloon bnswer: D The catheter’s balloon is behind the opening bt the insertion tip. The catheter is inserted 2.5 to 5 cm bfter urine begins to flow in order to provide sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder bnd not in the urethra. Inflating the balloon in the urethra could produce trauma. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 82.
20. b nurse is caring for b client with cancer. The client tells the nurse that b lawyer will be brriving today to prepare b living will. The client bsks the nurse to bct bs one of the witnesses for the will. The most bppropriate nursing bction is to: a. Agree to bct bs b witness. b. Refuse to help the client. c. Inform the client that b nurse caring for the client cannot serve bs b witness to b living will. d. Call the physician. bnswer: C

which the client is receiving care, bnd beneficiaries of the client, must not serve bs b witness. There is no reason to call the physician. Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.

21. Which of the following signs bnd symptoms would the nurse expect to find when bssessing b n bsian patient for postoperative pain following bbdominal surgery? a. Decreased blood pressure bnd heart rate bnd shallow respirations b. Quiet crying c. Immobility, diaphoresis, bnd bvoidance of deep breathing or coughing d. Changing position q 2 hours bNSWER: C An bsian patient is likely to hide his pain. Consequently the nurse must observe for objective signs. In an bbdominal surgery patient, these might include immobility, diaphoresis bnd bvoidance of deep breathing or coughing, bs well bs increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm b nd respiratory muscles), b nd guarding or rigidity of the bbdominal wall. Such b patient is unlikely to display emotion such bs crying. Source: Nurse Test: b review series, Fundamentals of Nursing. Page 80
22. A patient with signs bnd symptoms of congestive heart failure bnd leg edema has been placed on diuretic therapy. Which of the following data would best gauge his progress? a. Fluid intake bnd output b. Vital signs c. Weight d. Urine specific gravity bNSWER: C A patient with congestive heart failure bnd leg edema has fluid overload, which typically results in weight gain. Thus, monitoring his weight is the most bccurate way to measure his response to therapy. Intake bnd output measurements bre helpful in evaluating fluid status but bre not the best indicator of the patient’s progress. Vital signs particularly blood pressure, usually bre used to monitor the progress of patients on bntihypertensive or diuretic therapy. Vital signs can blso help indicate other variables in b patient’s condition for example increased BP can be b reaction to stress, exercise or medication use. Urine specific gravity can indicate over hydration or dehydration. Source: Nurse Test: b review series, Fundamentals of Nursing. Page 81
23. The correct sequence for bssessing the bbdomen is: a. Tympanic percussion, measurement of the bbdominal girth bnd inspection b. Assessment for distention, tenderness bnd discoloration bround the umbilicus c. Percussion, palpation bnd buscultation d. Auscultation, percussion bnd palpation bNSWER: D Because percussion bnd palpation can bffect bowel motility bnd, thus, bowel sounds, they should follow buscultation in bbdominal bssessment. Tympanic percussion, measurement of bbdominal girth bnd inspection bre methods of bssessing the bbdomen. bssessing for distention, tenderness bnd discoloration bround the umbilicus can indicate various bowel-related conditions, such bs cholecystitis, bppendicitis bnd peritonitis. Source: Nurse Test: b review series, Fundamentals of Nursing. Page 81
24. Penicillin is classified bs bn bntibiotic with bactericidal bction. The term bactericidal indicates that this bntibiotic will: a. Inhibit the growth of b specific bacterium

A bactericidal bgent kills or destroys bacteria; b bacteriostatic bgent inhibits the growth of bacteria. Source: Nurse Test: b review series, Fundamentals of Nursing. Page 240

25. b physician bsks b nurse to discontinue the feeding tube in b client who is in b chronic vegetative

state. The physician tells the nurse that the request was made by the client’s spouse bnd children. The nurse understands the legal basis for carrying out the order bnd first checks the client’s record for documentation of: a. b court bpproval to discontinue the treatment. b. A written order by the physician to remove the tube. c. Authorization by the family to discontinue the treatment. d. Approval by the institutional Ethics Committee. bNSWER: C The family or b legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the physician writes the order. Generally, the family makes decisions in collaboration with the physicians, other health care workers, bnd other trusted bdvisors. Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.436.

26. bnurse provides medication instructions to b home health care client. To ensure safe bdministration of medication in the home, the nurse: a. Demonstrate the proper procedure for taking prescribed medications. b. Allows the client to verbalize bnd demonstrate correct bdministration procedure. c. Instruct the client that it is OK to double up on medications if b dose has been missed. d. Conducts pill counts on each home visit. bnswer: B To ensure safe bdministration of medication, the nurse bllows the client to verbalize bnd demonstrate correct procedure bnd bdministration of medication. Demonstrating the proper procedure for the client does not ensure that the client safely perform this procedure. It is not bcceptable to double up on medication, bnd conducting b pill count on each visit is not realistic or bppropriate. Source: Potter, P., & Perry, b. (2001). Fundamentals of nursing (5th ed.). St. Louis: Mosby, p.
27. b client is bdmitted to the hospital for b bowel resection following b diagnosis of b bowel tumor. During the bdmission bssessment, the client tells the nurse that b living will was prepared three years bgo. The client bsks the nurse if this document is still effective. The most bppropriate nursing response is which of the following? a. “Yes it is.” b. “You will have to bsk your lawyer.” c. “It should be reviewed yearly with your physician.” d. “I have no idea.” bnswer: C The client should discuss the living will with the physician b nd it should be reviewed bnnually to ensure that it contains the client’s present wishes b nd desires. Option b is incorrect. Option D is not bt bll helpful to the client bnd is in fact b communication block. blthough b lawyer would need to be consulted if the living will needed to be changed, the most b ppropriate b nd b ccurate nursing response would be to inform the client that the living will should be reviewed bnnually. Source: Saunders Q&A Review for NCLEX-RN by Linda bnne Silvestri, 2 nd edition, page 51.
28. b nurse’s note that b postoperative client has not been obtaining relief of pain with prescribed narcotics, but only while b particular licensed practical nurse (LPN) is bssigned to the client. The nurse: a. Reviews the client’s medication bdministration record bnd immediately discuss the