1. Answer: D.

 Portal of entry

Option D: In the circular chain of infection, pathogens must be able to leave their reservoir and be
transmitted to a susceptible host through a portal of entry, such as broken skin.

2. Answer: C. Opening the door of the patient’s room leading into the hospital corridor

 Option C: Respiratory isolation, like strict isolation, requires that the door to the door patient’s
room remain closed.

 Options A and B: However, the patient’s room should be well ventilated, so opening the
window or turning on the ventricular is desirable.

 Option D: The nurse does not need to wear gloves for respiratory isolation, but good hand
washing is important for all types of isolation.

3. Answer: A. A patient with leukopenia

 Option A: Leukopenia is a decreased number of leukocytes (white blood cells), which are
important in resisting infection.

Options B, C, and D: None of the other situations would put the patient at risk for contracting an
infection; taking broad-spectrum antibiotics might actually reduce the infection risk.

4. Answer: A. Soap or detergent to promote emulsification

 Option A: Soaps and detergents are used to help remove bacteria because of their ability to
lower the surface tension of water and act as emulsifying agents.

 Option B: Hot water may lead to skin irritation or burns.

5. Answer: A. 30 seconds

 Option A: Depending on the degree of exposure to pathogens, hand washing may last from 10

seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively
minimizes the risk of pathogen transmission.

6. Answer: B. Urinary catheterization

 Option B: The urinary system is normally free of microorganisms except at the urinary meatus.
Any procedure that involves entering this system must use surgically aseptic measures to
maintain a bacteria-free state.

7. Answer: C. Invasive procedures are performed

 Option C: All invasive procedures, including surgery, catheter insertion, and administration of
parenteral therapy, require sterile technique to maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for all invasive procedures.

 Option A: Strict isolation requires the use of clean gloves, masks, gowns and equipment to
prevent the transmission of highly communicable diseases by contact or by airborne routes.

 Option B: Terminal disinfection is the disinfection of all contaminated supplies and equipment
after a patient has been discharged to prepare them for reuse by another patient.
  Option D: The purpose of protective (reverse)isolation is to prevent a person with seriously
impaired resistance from coming into contact who potentially pathogenic organisms.

8. Answer: C. Placing a sterile object on the edge of the sterile field

 Option C: The edges of a sterile field are considered contaminated. When sterile items are
allowed to come in contact with the edges of the field, the sterile items also become
contaminated.

9. Answer: B. Body hair

 Option B: Hair on or within body areas, such as the nose, traps and holds particles that contain
microorganisms.

 Options A and C: Yawning and hiccupping do not prevent microorganisms from entering or
leaving the body.

 Option D: Rapid eye movement marks the stage of sleep during which dreaming occurs.

10. Answer: D. The inside of the glove is considered sterile

 Option D: The inside of the glove is always considered to be clean, but not sterile.

11. Answer: A. Waist tie and neck tie at the back of the gown

 Option A: The back of the gown is considered clean, the front is contaminated. So, after
removing gloves and washing hands, the nurse should untie the back of the gown; slowly move
backward away from the gown, holding the inside of the gown and keeping the edges off the
floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash
her hands again.

12. Answer: B. Discard all used uncapped needles and syringes in an impenetrable protective
container

 Option B: According to the Centers for Disease Control (CDC), blood-to-blood contact occurs
most commonly when a health care worker attempts to cap a used needle.

 Option A: Therefore, used needles should never be recapped; instead they should be inserted in
a specially designed puncture resistant, labeled container.

 Option C: Wearing gloves is not always necessary when administering an I.M. injection.

 Option D: Enteric precautions prevent the transfer of pathogens via feces.

13. Answer: A. Massaging the reddened area with lotion

 Option A: Nurses and other healthcare professionals previously believed that massaging a
reddened area with lotion would promote venous return and reduce edema to the area.
However, research has shown that massage only increases the likelihood of cellular ischemia
and necrosis to the area.

14. Answer: B. Blood typing and cross-matching

 Option B: Before a blood transfusion is performed, the blood of the donor and recipient must be
checked for compatibility. This is done by blood typing (a test that determines a person’s blood
type) and cross-matching (a procedure that determines the compatibility of the donor’s and
recipient’s blood after the blood types has been matched). If the blood specimens are
incompatible, hemolysis and antigen-antibody reactions will occur.
15. Answer: A. Potential for clot formation

 Option A: Platelets are disk-shaped cells that are essential for blood coagulation. A platelet
count determines the number of thrombocytes in blood available for promoting hemostasis and
assisting with blood coagulation after injury.

 Option B: It also is used to evaluate the patient’s potential for bleeding; however, this is not its
primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of
100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is
associated with spontaneous bleeding.

16. Answer: D. 25,000/mm³

 Option D: Leukocytosis is any transient increase in the number of white blood cells (leukocytes)
in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of
25,000/mm3 indicates leukocytosis.

17. Answer: A. Hypokalemia

 Option A: Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an

inadequate potassium level), which is a potential side effect of diuretic therapy. The physician
usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics.

 Option C: Anorexia is another symptom of hypokalemia.

 Option D: Dysphagia means difficulty swallowing.

18. Answer: A. No contradictions exist for this test

 Option A: Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray.
However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic
region from radiation.

 Option B: Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should
not be worn above the waist.

 Option C: A signed consent is not required because a chest X-ray is not an invasive examination.

 Option D: Eating, drinking and medications are allowed because the X-ray is of the chest, not the
abdominal region.

19. Answer: A. Early in the morning

 Option A: Obtaining a sputum specimen early in this morning ensures an adequate supply of
bacteria for culturing and decreases the risk of contamination from food or medication.

20. Answer: A. Withhold the moderation and notify the physician

 Option A: Initial sensitivity to penicillin is commonly manifested by a skin rash, even in

individuals who have not been allergic to it previously. Because of the danger of anaphylactic
shock, the nurse should withhold the drug and notify the physician, who may choose to
substitute another drug.

 Option C: Administering an antihistamine is a dependent nursing intervention that requires a

written physician’s order.

 Option D: Although applying cornstarch to the rash may relieve discomfort, it is not the nurse’s
top priority in such a potentially life-threatening situation.
21. Answer: D. Rub the site vigorously after the injection to promote absorption

 Option D: The Z-track method is an I.M. injection technique in which the patient’s skin is pulled
in such a way that the needle track is sealed off after the injection. This procedure seals
medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the
injection site is contraindicated because it may cause the medication to extravasate into the
skin.

22. Answer: D. Divide the area between the greater femoral trochanter and the lateral femoral
condyle into thirds, and select the middle third on the anterior of the thigh

 Option D: The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is
viewed by many clinicians as the site of choice for I.M. injections because it has relatively few
major nerves and blood vessels. The middle third of the muscle is recommended as the injection
site. The patient can be in a supine or sitting position for an injection into this site.

23. Answer: A. Can accommodate only 1 ml or less of medication

 Option A: The mid-deltoid injection site can accommodate only 1 ml or less of medication

because of its size and location (on the deltoid muscle of the arm, close to the brachial artery
and radial nerve).

24. Answer: D. 25G, 5/8” long

 Option D: A 25G, 5/8” needle is the recommended size for insulin injection because insulin is
administered by the subcutaneous route.

 Option A: An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the
vastus lateralis.

 Option C: A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically
administered in the vastus lateralis or ventrogluteal site.

25. Answer: D. 26G

 Option D: Because an intradermal injection does not penetrate deeply into the skin, a small-
bore 26G-27G needle is recommended. This type of injection is used primarily to administer
antigens to evaluate reactions for allergy or sensitivity studies.
Options A, B, and C: A 20G needle is usually used for I.M. injections of oil-based medications; a
22G-25G needle for I.M. injections; and a 25G needle, for subcutaneous insulin injections.

26. Answer: D. Encourage the patient to increase his fluid intake, use non-
irritating soap when bathing the patient, and apply lotion to the involved
areas

Dry skin will eventually crack, ranking the patient more prone to infection. To
prevent this, the nurse should provide adequate hydration through fluid intake,
use nonirritating soaps or no soap when bathing the patient, and lubricate the
patient’s skin with lotion. Bathing may be limited but need not be avoided
entirely. The attending physician and dietitian may be consulted for treatment,
but home-laundered items usually are not necessary.

27. Answer: C. Increases venous blood return

Washing from distal to proximal areas stimulates venous blood flow, thereby
preventing venous stasis. It improves circulation but does not result in
vasoconstriction. The nurse can assess the patient’s condition throughout the
bath, regardless of washing technique, and should feel no strain while bathing
the patient.

28. Answer: B. Rapid eye movement (REM) stage

Other characteristics of rapid eye movement (REM) sleep are deep sleep (the
patient cannot be awakened easily), depressed muscle tone, and possibly
irregular heart and respiratory rates. Non-REM sleep is a deep, restful sleep
without dreaming. Delta stage, or slow-wave sleep, occurs during non-REM
Stages III and IV and is often equated with quiet sleep.

29. Answer: C. Tryptophan

Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril),

and methotrimeprazine (Levoprome) are hypnotic sedatives.

30. Answer: A. Have the patient take a 30- to 60-minute nap in the
afternoon

Napping in the afternoon is not conductive to nighttime sleeping. Quiet music,

watching television, reading, and massage usually will relax the patient, helping
him to fall asleep.

31. Answer: D. Prevent a patient from becoming confused or disoriented

By restricting a patient’s movements, restraints may increase stress and lead

to confusion, rather than prevent it. The other choices are valid reasons for
using restraints.

32. Answer: D. All of the above

When applying restraints, the nurse must document the type of behavior that
prompted her to use them, document the type of restraints used, and obtain a
physician’s written order for the restraints.

33. Answer: C. Denial, anger, bargaining, depression acceptance

Kubler-Ross’s five successive stages of death and dying are denial, anger,

bargaining, depression, and acceptance. The patient may move back and forth
through the different stages as he and his family members react to the process
of dying, but he usually goes through all of these stages to reach acceptance.
34. Answer: C. Numbness

Numbness is typical of the depression stage, when the patient feels a great
sense of loss. The anger stage includes such feelings as rage, envy, resentment,
and the patient’s questioning “Why me?”

35. Answer: C. Reflecting on the significance of death

According to thanatologists, reflecting on the significance of death helps to

reduce the fear of death and enables the health care provider to better
understand the terminally ill patient’s feelings. It also helps to overcome the
belief that medical and nursing measures have failed, when a patient cannot be
cured.

36. Answer: C. Fixed, dilated pupils

Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid,
muscles become weak and atonic, and periods of apnea occur during
respiration.

37. Answer: B. Centers for Disease Control (CDC)

The Center of Disease Control (CDC) publishes and frequently updates

guidelines on caring for patients who require isolation. The National League of
Nursing’s (NLN’s) major function is accrediting nursing education programs in
the United States. The American Medical Association (AMA) is a national
organization of physicians. The American Nurses’ Association (ANA) is a national
organization of registered nurses.

38. Answer: A. Organism’s mode of transmission

Before instituting isolation precaution, the nurse must first determine the
organism’s mode of transmission. For example, an organism transmitted
through nasal secretions requires that the patient be kept in respiratory
isolation, which involves keeping the patient in a private room with the door
closed and wearing a mask, a gown, and gloves when coming in direct contact
with the patient. The organism’s Gram-straining characteristics reveal whether
the organism is gram-negative or gram-positive, an important criterion in the
physician’s choice for drug therapy and the nurse’s development of an effective
plan of care. The nurse also needs to know whether the organism is susceptible
to antibiotics, but this could take several days to determine; if she waits for the
results before instituting isolation precautions, the organism could be
transmitted in the meantime. The patient’s susceptibility to the organism has
already been established. The nurse would not be instituting isolation
precautions for a non-infected patient.
39. Answer: C. Have the patient expectorate the sputum into a sterile
container

Placing the specimen in a sterile container ensures that it will not become
contaminated. The other answers are incorrect because they do not mention
sterility and because antiseptic mouthwash could destroy the organism to be
cultured (before sputum collection, the patient may use only tap water for
nursing the mouth).

40. Answer: D. Pressurized steam penetrates the supplies better

An autoclave, an apparatus that sterilizes equipment by means of high-

temperature pressurized steam, is used because it can destroy all forms of
microorganisms, including spores.

41. Answer: C. Gently pull just below the cuff and invert the gloves when
removing them

Turning the gloves inside out while removing them keeps all contaminants
inside the gloves. They should then be placed in a plastic bag with soiled
dressings and discarded in a soiled utility room garbage pail (double bagged).
The other choices can spread pathogens within the environment.

42. Answer: C. Phlebitis

Tenderness, warmth, swelling, and, in some instances, a burning sensation are

signs and symptoms of phlebitis. Infection is less likely because no drainage
or fever is present. Infiltration would result in swelling and pallor, not erythema,
near the insertion site. The patient has no evidence of bleeding.

43. Answer: B. Roll the vial gently between the palms

Gently rolling a sealed vial between the palms produces sufficient heat to
enhance dissolution of a powdered medication. Shaking the vial vigorously can
break down the medication and alter its pharmacologic action. Inverting the vial
or leaving it alone does not ensure thorough homogenization of the powder and
the solvent.

44. Answer: C. Check the syringe to verify that the nurse has removed the
prescribed insulin dose

When the nurse teaches the patient to prepare an insulin injection, the patient’s
first priority is to validate the dose accuracy. The next steps are to select the site,
assess the site, and clean the site with alcohol before injecting the insulin.

45. Answer: A. 25 gtt/minute

 46. Answer: A. 0.5 ml

47. Answer: B. Draw up the regular insulin, then the NPH insulin, in the
same syringe

Drugs that are compatible may be mixed together in one syringe. In the case of
insulin, the shorter-acting, clear insulin (regular) should be drawn up before the
longer-acting, cloudy insulin (NPH) to ensure accurate measurements.

48. Answer: C. Observe the emesis

After a patient has vomited, the nurse must inspect the emesis to document
color, consistency, and amount. In this situation, the patient recently ingested
medication, so the nurse needs to check for remnants of the medication to help
determine whether the patient retained enough of it to be effective. The nurse
must then notify the physician, who will decide whether to repeat the dose or
prescribe an antiemetic.

49. Answer: B. His 24-hour output is adequate

A 24-hour urine output of less than 500 ml in an adult is considered inadequate

and may indicate kidney failure. This must be corrected while the patient is in
the acute state so that appropriate fluids, electrolytes, and medications can be
administered and excreted. Indwelling catheterization is not needed to diagnose
trauma, urinary tract infection, or residual urine.

50. Answer: B. Making changes after evaluating the situation and having
discussions with the staff. 

A new assistant nurse manager should not make changes until she has had a
chance to evaluate staff members, patients, and physicians. Changes must be
planned thoroughly and should be based on a need to improve conditions, not
just for the sake of change. Written assignments allow all staff members to
know their own and others responsibilities and serve as a checklist for the
manager, enabling her to gauge whether the unit is being run effectively and
whether patients are receiving appropriate care. Telling the staff nurses that she
is making changes to benefit their performance should occur only after the
nurse has made a thorough evaluation. Evaluations are usually done on a yearly
basis or as needed.

51. Answer: B. Administering a measles, mumps, and rubella immunization to

an infant

Immunizing an infant is an example of primary prevention, which aims to prevent

health problems. Administering digoxin to treat heart failure and obtaining a smear
for a screening test are examples for secondary prevention, which promotes early
detection and treatment of disease. Using occupational therapy to help a patient
cope with arthritis is an example of tertiary prevention, which aims to help a patient
deal with the residual consequences of a problem or to prevent the problem from
recurring.

52. Answer: B. Inspection

Inspection always comes first when performing a physical examination. Percussion

and palpation of the abdomen may affect bowel motility and therefore should
follow auscultation.

53. Answer: D. S1 is loudest at the apex, and S2 is loudest at the base

The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds
longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is
loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

54. Answer: B. Nursing diagnosis

The nurse identifies human responses to actual or potential health problems

during the nursing diagnosis step of the nursing process. During the assessment
step, the nurse systematically collects data about the patient or family. During the
planning step, the nurse develops strategies to resolve or decrease the patient’s
problem. During the evaluation step, the nurse determines the effectiveness of the
plan of care.

55. Answer: B. Bananas and oranges

Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach

the patient to increase intake of potassium-rich foods, such as bananas and
oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good
sources of potassium.

56. Answer: D. Bone marrow suppression

The most toxic reaction to chloramphenicol is bone marrow suppression.

Chloramphenicol is not known to cause lethal arrhythmias,
malignant hypertension, or status epilepticus.

57. Answer: D. Altered peripheral tissue perfusion related to venous

congestion

Altered peripheral tissue perfusion related to venous congestion” takes highest

priority because venous inflammation and clot formation impede blood flow in a
patient with deep-vein thrombosis. Option A is incorrect because impaired gas
exchange is related to decreased, not increased, blood flow. Option B is
inappropriate because no evidence suggest that this patient has a fluid volume
excess. Option C may be warranted but is secondary to altered tissue perfusion.

58. Answer: A. Superior vena cava

When the central venous catheter is positioned correctly, its tip lies in the superior
vena cava, inferior vena cava, or the right atrium—that is, in central venous
circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of
large amounts of fluid directly into circulation. The basilica, jugular, and subclavian
veins are common insertion sites for central venous catheters.

59. Answer: D. Evaluation

During the evaluation step of the nursing process the nurse determines whether
the goals established in the care plan have been achieved, and evaluates the
success of the plan. If a goal is unmet or partially met the nurse reexamines the
data and revises the plan. Assessment involves data collection. Planning involves
setting priorities, establishing goals, and selecting appropriate interventions.

60. Answer: C. “With your history and the type of location of the injury, it’s
hard to say.”

Wound healing in a client with diabetes will be delayed. Providing the client with a
time frame could give the client false information.

61. Answer: B. Documenting drugs given

Although documentation isn’t a step in the nursing process, the nurse is legally
required to document activities related to drug therapy, including the time of
administration, the quantity, and the client’s reaction. Developing a content outline,
establishing outcome criteria, and setting realistic client goals are part of planning
rather than implementation.

62. Answer: B. Recent pelvic surgery

The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in
blood supply, and thrombophlebitis of the deep vein is associated with pelvic
surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease
the client’s risk of DVT. In general, diabetes is a contributing factor associated with
peripheral vascular disease.

63. Answer: D. Provide the client with normal sleep aids, such as pillows, back
rubs, and snacks

The nurse should begin with the simplest interventions, such as pillows or snacks,
before interventions that require greater skill such as relaxation techniques. Sleep
medication should be avoided whenever possible. At some point, the nurse should
do a thorough sleep assessment, especially if common sense interventions fail.

64. Answer: C. Moist, sterile saline gauze

Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile
dressings adhere to the wound and debride the tissue when removed. Petroleum
supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it
shouldn’t be left on an open wound.

65. Answer: C. Upcoding

Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than
the code for the service actually provided. Unbundling, overbilling, and
misrepresentation aren’t the terms used for this illegal practice.

66. Answer: D. Suggest referral to a sex counselor or other appropriate

professional

The nurse should refer this client to a sex counselor or other professional. Making
appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t
normally provide sex counseling. Therefore, providing time for privacy and
providing support for the spouse or significant other are important, but not as
important as referring the client to a sex counselor.

67. Answer: B. Elimination

According to Maslow, elimination is a first-level or physiological need, and therefore

takes priority over all other needs. Security and safety are second-level needs;
belonging is a third-level need. Second- and third-level needs can be met only after
a client’s first-level needs have been satisfied.

68. Answer: B. Inadequate protein intake

A client on bed rest suffers from a lack of movement and a negative nitrogen
balance. Therefore, inadequate protein intake impairs wound healing. Inadequate
vitamin D intake and low calcium levels aren’t factors in poor healing for this client.
A pressure ulcer should never be massaged.

69. Answer: D. Risk for aspiration related to anesthesia

Risk for aspiration related to anesthesia takes priority for this client because
general anesthesia may impair the gag and swallowing reflexes, possibly leading to
aspiration. The other options, although important, are secondary.
70. Answer: C. Petechiae

Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the
interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess
of urea and other nitrogen products in the blood.

71. Answer: B. Patient’s Bill of Rights

The Patient’s Bill of Rights addresses the client’s right to information, informed
consent, timely responses to requests for services, and treatment refusal. A legal
document, it serves as a guideline for the nurse’s decision making. Standards of
Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing
practice parameters and primarily describe the use of the nursing process in
providing care.

72. Answer: B. Produce a false-high measurement

Using an undersized blood pressure cuff produces a falsely elevated blood

pressure because the cuff can’t record brachial artery measurements unless it’s
excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the
blood pressure cuff because the sciatic nerve is located in the lower extremity.

73. Answer: A. Baked beans, hamburger, and milk

Baked beans, hamburger, and milk are all excellent sources of protein. The
spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda
choice provides liquid and sodium as well as some iron, vitamins, and
carbohydrates. Chicken provides protein but the chicken-spinach-soda combination
provides less protein than the baked beans-hamburger-milk selection.

74. Answer: A. Assess the client’s airway

The first priority is to evaluate airway patency before assessing for signs of
obstruction, sternal retraction, stridor, or wheezing. Airway management is always
the nurse’s first priority. Pain management and splinting are important for the
client’s comfort, but would come after airway assessment. Coughing and deep
breathing may be contraindicated if the client has internal bleeding and other
injuries.

75. Answer: B. Unexpected feeling and emotions among the staff

The usual or most prevalent reason for lack of productivity in a group of competent
nurses is inadequate communication or a situation in which the nurses have
unexpected feeling and emotions. Although the other options could be contributing
to the problematic situation, they’re less likely to be the cause.
76. Answer: B. Prevent infection

The client is at risk for infection because WBC count is dangerously low. Hb level
and HCT are within normal limits; therefore, fluid balance, rest, and prevention of
injury are inappropriate.

77. Answer: D. Side-lying

Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from
the surgical wound. Therefore, placing the client in the side-lying position until he
awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for
adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk
of blood aspiration.

78. Answer: A. Anisocoria

Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary

muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.

79. Answer: A. He may have a low threshold for pain

People of Italian heritage tend to verbalize discomfort and pain. The pain was real
to the client, and he may need medication when he wakes up.

80. Answer: D. Fluid overload

Fluid overload causes the volume of blood within the vascular system to increase.
This increase causes the vein to distend, which can be seen most obviously in the
neck veins. A neck tumor doesn’t typically cause jugular vein distention. An
electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute
to jugular vein distention.

81. Answer: A. Are important to use in nursing practice

Nurses make many decisions: some require using the nursing process, whereas
others are not client related but require critical thinking. The nursing process has
specific steps; critical thinking does not. Neither is linear. Critical thinking applies to
any discipline.

82. Answer: B. Diagnosis

In the assessment phase, the nurse gathers data from many sources for analysis in
the diagnosis phase. In the diagnosis phase, the nurse identifies the client’s health
status. In the planning outcomes phase, the nurse formulates goals and outcomes.
In the evaluation phase, which occurs after implementing interventions, the nurse
gathers data about the client’s responses to nursing care to determine whether
client outcomes were met.

83. Answer: D. Evaluation

In the assessment phase, the nurse gathers data from many sources for analysis in
the diagnosis phase. In the diagnosis phase, the nurse identifies the client’s health
status. In the planning outcomes phase, the nurse and client decide on goals they
want to achieve. In the intervention planning phase, the nurse identifies specific
interventions to help achieve the identified goal. During the implementation phase,
the nurse carries out the interventions or delegates them to other health care team
members. During the evaluation phase, the nurse judges whether her actions have
been successful in treating or preventing the identified client health problem.

84. Answer: A. Identify personal biases that may affect his thinking and
actions

The most basic reason is that self-knowledge directly affects the nurse’s thinking
and the actions he chooses. Indirectly, thinking is involved in identifying effective
interventions, communicating, and learning procedures. However, because
identifying personal biases affects all the other nursing actions, it is the most basic
reason.

85. Answer: C. “A, E, C, D, B”

Logically, the steps are assessment, diagnosis, planning outcomes, planning

interventions, and evaluation. Keep in mind that steps are not always performed in
this order, depending on the patient’s needs, and that steps overlap.

86. Answer: A. Influences on the nurse’s problem solving and decision making

Cognitive skills are used in complex thinking processes, such as problem solving
and decision making. Critical thinking attitudes determine how a person uses her
cognitive skills. Critical thinking attitudes are traits of the mind, such as
independent thinking, intellectual curiosity, intellectual humility, and fair-
mindedness, to name a few. Critical thinking skills refer to the cognitive activities
used in complex thinking processes. A few examples of these skills involve
recognizing the need for more information, recognizing gaps in one’s own
knowledge, and separating relevant from irrelevant data. Critical thinking, which
consists of intellectual skills and attitudes, can be used in all aspects of life.

87. Answer: B. Self-knowledge

Personal knowledge is self-understanding—awareness of one’s beliefs, values,

biases, and so on. That best describes the nurse’s awareness that her bias can
affect her patient care. Theoretical knowledge consists of information, facts,
principles, and theories in nursing and related disciplines; it consists of research
findings and rationally constructed explanations of phenomena. Using reliable
resources is a critical thinking skill. The nursing process is a problem-solving
process consisting of the steps of assessing, diagnosing, planning outcomes,
planning interventions, implementing, and evaluating. The nurse has not yet met
this patient, so she could not have begun the nursing process.

88. Answer: D. The Joint Commission

The Joint Commission has developed assessment standards, including that all
clients be assessed for pain. The ANA has developed standards for clinical practice,
including those for assessment, but not specifically for pain. State nurse practice
acts regulate nursing practice in individual states. The NCSBN asserts that the scope
of nursing includes a comprehensive assessment but does not specifically include
pain.

89. Answer: B. The client states she feels feverish; you measure the oral
temperature at 98°F.

Validation should be done when subjective and objective data do not make sense.
For instance, it is inconsistent data when the patient feels feverish and you obtain a
normal temperature. The other distractors do not offer conflicting data. Validation
is not usually necessary for laboratory test results.

90. Answer: D. Sitting, facing the client in a chair at the client’s bedside, using
active listening

Active listening should be used during an interview. The nurse should face the
patient, have relaxed posture, and keep eye contact. Asking “why” may make the
client defensive. Note-taking interferes with eye contact. The client may not
understand medical terminology or health care jargon.

91. Answers: C, D

Nursing models produce a holistic database that is useful in identifying nursing

rather than medical diagnoses. Body systems and head-to-toe are not nursing
models, and they are not holistic; they focus on identifying physiological needs or
disease. Maslow’s hierarchy is not a nursing model, but it is holistic, so it is
acceptable for identifying nursing diagnoses. Gordon’s functional health patterns
are a nursing model.

92. Answer: A, C, D

The nurse recorded a vague generality: “he has had a good night.” The nurse did
not use the patient’s exact words, but she did not quote the patient at all, so that is
not one of her errors. The nurse used the “waffle” word, “seems” worried instead of
documenting what the patient said or did to lead her to that conclusion. The nurse
recorded these inferences: worried and had a good night.

93. Answer: C. Focused physical assessment

The nurse is performing a focused physical assessment, which is done to obtain

data about an identified problem, in this case shortness of breath. An ongoing
assessment is performed as needed, after the initial data are collected, preferably
with each patient contact. A comprehensive physical assessment includes an
interview and a complete examination of each body system. A psychosocial
assessment examines both psychological and social factors affecting the patient.
The nurse conducting a psychosocial assessment would gather information about
stressors, lifestyle, emotional health, social influences, coping patterns,
communication, and personal responses to health and illness, to name a few
aspects.

94. Answer: A. Sitting upright

If the patient is able, the nurse should have the patient sit upright to obtain vital
signs in order to allow the nurse to easily access the anterior and posterior chest
for auscultation of heart and breath sounds. It allows for full lung expansion and is
the preferred position for measuring blood pressure. Additionally, patients might
be more comfortable and feel less vulnerable when sitting upright (rather than
lying down on the back) and can have direct eye contact with the examiner.
However, other positions can be suitable when the patient’s physical condition
restricts the comfort or ability of the patient to sit upright.

95. Answer: B. “C, A, D, B”

Inspection begins immediately as the nurse meets the patient, as she observes the
patient’s appearance and behavior. Observational data are not intrusive to the
patient. When performing assessment techniques involving physical touch, the
behavior, posture, demeanor, and responses might be altered. Palpation,
percussion, and auscultation should be performed in that order, except when
performing an abdominal assessment. During abdominal assessment, auscultation
should be performed before palpation and percussion to prevent altering bowel
sounds.

96. Answer: A. Sims’

Sims’ position is typically used to examine the rectal area. However, the position
should be avoided if the patient has undergone hip replacement surgery The
patient with a hip replacement can assume the supine, dorsal recumbent, or semi-
Fowler’s positions without causing harm to the joint. Supine position is lying on the
back facing upward. The patient in dorsal recumbent is on his back with knees
flexed and soles of feet flat on the bed. In semi-Fowler’s position, the patient is
supine with the head of the bed elevated and legs slightly elevated.

97. Answer: B. Demonstrate equipment before using it.

The nurse should modify his examination by demonstrating equipment before

using it to examine a school-age child. The nurse should make sure parents are not
present during the physical examination of an adolescent, but they usually help
younger children feel more secure. The nurse should allow a preschooler to help
with the examination when possible, but not usually a school-age child. Toddlers
are often fearful of invasive procedures, so those should be performed last in this
age group. It is best to perform invasive procedures last for all age groups;
therefore, this does not represent a modification.

98. Answer: B. Semi-Fowler’s

If a patient is unable to sit up, the nurse should place him lying flat on his back, with
the head of the bed elevated. Dorsal recumbent position is used for abdominal
assessment if the patient has abdominal or pelvic pain. The patient in dorsal
recumbent is on his back with knees flexed and soles of feet flat on the bed.
Lithotomy position is used for female pelvic examination. It is similar to dorsal
recumbent position, except that the patient’s legs are well separated and thighs are
acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket
crosswise over thighs and legs so that genital area is easily exposed. Keep patient
covered as much as possible. The patient in Sim’s position is on left side with right
knee flexed against abdomen and left knee slightly flexed. Left arm is behind body;
right arm is placed comfortably. Sims’ position is used to examine the rectal area. In
semi-Fowler’s position, the patient is supine with the head of the bed elevated and
legs slightly elevated.

99. Answer: C. Bowel sounds

The bell of the stethoscope should be used to hear low-pitched sounds, such as
murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-
pitched sounds that normally occur in the heart, lungs, and abdomen.

100. Answer: D. Underweight

For adults, BMI should range between 20 and 25; BMI less than 20 is considered
underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered
obese.