Title WORKBOOK - FUNDA (KEY) ✅

A. Call the family so they can expect the patient at home B. Allow the patient to leave because no one can be held against his or her will C. Call security because there must be a physician’s order before a patient may leave D. Explain the risk of leaving and request that the patient sign a paper accepting responsibility for problems that may occur 12. Which among the following is the most appropriate action of the nurse during the client’s discharge? A. Tell the patient everything will be all right B. Encourage the patient not to worry C. Wish the patient well D. Introduce the patient to the office staff Situation: Hygiene is the science of health and its preservation. Hygiene is personal matter established by individual’s values and practices. The nurse must be knowledgeable in the proper ways of rendering hygienic care to clients. 13. A nurse is bathing a 10year old client with a cast on the left leg. Which of the following actions is appropriate for the nurse do when providing eye care? A. To wash from the outer canthus to inner canthus B. To cleanse dried exudate with hot water C. To avoid drying circumorbital area after washing D. To use a different section of washcloth for each eye 14. A nurse is to render perineal care to an 80 year old male client 1 day post TURP. Which among the following is most appropriate action of the nurse? A. Retract the foreskin, cleanse the penis, and allow the foreskin to return to former position B. Sprinkle powder under the foreskin to facilitate retraction of the foreskin C. Leave the foreskin slightly damp to allow retraction to its former state D. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion 15. Which among the following clients has the highest risk for complication of the feet? A. A young man in a career that requires standing B. A disoriented, elderly man C. A 60-year-old person with diabetes mellitus D. A 62-year-old patient with total hip replacement Situation: Pressure ulcer is any lesions brought by unrelieved pressure leading to the damage of the underlying tissue. It is most common among clients who are confined in bed. 16. When the nurse is placing the client on a 30 degrees lateral position, she is preventing the client to develop pressure ulcer over which of the following areas? A. Spinous processes B. Ischial tuberosities C. Greater tronchanters D. Temporal area 17. Which among the following pertains to stage III pressure ulcers? A. Nonblanchable reddened areas where the skin is intact B. Full-thickness skin loss extending to but not through the fascia C. Extensive destruction of skin and muscle with possible sinus tracts D. Areas of full-thickness skin loss with possible extension to the bone Situation: Conduction of surgical procedures may vary in every health care institution but providing quality care and ensuring client’s safety is a mutual aim among every health care facilities. 18. A nurse is caring for a female client with Penrose drain in the left lower quadrant, who has been returned to the medical-surgical unit from the post anesthesia care unit. The nurse knows that the Penrose drain was placed to A. instill solution for wound irrigation B. prevent blockage of a passageway C. drain the wound area by suction D. drain the wound area by gravity 19. While doing an assessment to the client, the nurse noticed that the client’s abdominal wound eviscerated, the nurse should; A. Place her in high Fowler’s position B. Give her fluids to prevent shock C. Replace dressings with sterile fluffy pads D. Apply warm, moist sterile dressings 20. A client was prescribed to wear an antiembolic stocking. The nurse should initially; A. Measure the legs before applying stockings to assure proper fit B. Apply the stockings while the client is sitting in a chair C. Massage the legs when removing the stockings D. Leave the stockings in place for one week intervals 21. The OR nurse must be aware of the surgical environment and the proper attire in each area. Which of the following constitute a break in infection control which may cause contamination in the OR? A. The spouse of the client enters the unrestricted area in street clothes. B. The OR nurse wear surgical attire when going to the storage areas. C. The OR nurse is wearing scrub attire in the restricted area. D. The OR nurse wear surgical scrubs alone in the OR room when preparing for the instruments. Situation: Infection control is one of the most important parts of health care. It is concerned on preventing nosocomial or health care related infection 22. To be able to protect the client’s first line of defense against infection, the nurse should do which of the following? A. Turn the client who is immobilized every 2 hours so the skin does not break down. TOP RANK REVIEW ACADEMY, INC. Page 2 | 9
B. Collect an immunization history on the client. C. Apply heat immediately after an injury. D. Desensitize the client by providing small doses of allergen. 23. A client was admitted to the hospital after sustaining a traumatic abdominal injury. Prior to undergoing a surgery to remove the spleen, the nurse should instruct the client to avoid which of the following? A. Carcinogens such as smoking B. Animal dander causing allergies C. Cuts leading to bloodstream infections D. Irritants causing dermatitis 24. Which of the following actions of the nurse demonstrates surgical asepsis? A. Wearing clean gloves to change linen. B. Cleaning the client’s skin with povidone/iodine and alcohol before inserting an intravenous catheter. C. Putting on a HEPA mask when entering the room of a client with tuberculosis. D. Placing a used syringe in a sharps container. 25. Which element of the chain of infection is being broken when the nurse uses sterile technique in changing soiled surgical dressing? A. Transmission B. Infectious agent C. Host D. Reservoir 26. Which of the following actions would be helpful in preventing the development of hospital acquired infection among clients? A. Wearing a mask when changing the dressing on the client’s central line B. Rising the suction catheter with normal saline after suctioning the client’s tracheostomy tube C. Wearing clean gloves to remove the lunch tray of a client with hepatitis A. D. Wearing clean gloves to empty a would drain 27. Older clients are at a higher risk of acquiring infection because of which of the following characteristics? A. Increased production of saliva B. Increased cough effort C. Increased cell-mediated immunity D. Thinning of the skin SITUATION: Basic nursing skills are essential for they are vital in many nursing procedures. Such skills are needed in order to promote health, prevent illness, cure a disease and rehabilitate infirmities. 28. A client with anemia is prescribed to receive iron injection. The nurse is aware that this medication should be administered in the: A. Gluteal muscle using Z-Track technique B. Deltoid muscle using an air lock C. Subcutaneous tissue of the abdomen D. Anterolateral thigh using 5/8-inch needle 29. A 28 year old female client is to undergo cerebral angiogram. Prior to the procedure the nurse should assess the client for: A. Claustrophobia B. Excessive weight C. Allergy to eggs D. Allergy to iodine or shellfish 30. The physician ordered for a client to have a wound culture to be obtained during the next wound irrigation and dressing change. Which of the following is the most appropriate solution to be use for the wound irrigation prior to the procedure? A. Povidone-iodine (Betadine) B. One-half-strength hydrogen peroxide C. Normal saline D. Acetic acid 31. To determine the necessity to perform an airway suctioning, the nurse should check the client’s: A. Oxygen saturation measurement B. Respiratory rate C. Breath sounds D. Arterial blood gas results 32. A nurse is caring for a diabetic client. She is assisting the client in performing self monitoring of blood glucose level. The nurse should teach the client to do which of the following to obtain an adequate capillary sample? A. Cleanse the hands beforehand using cool water B. Let the arm hang dependently and milk the digit C. Puncture the center of the finger pad D. Puncture the finger with enough depth Situation: A 45 year old male client has been admitted to the medical surgical unit with a diagnosis of acute pancreatitis. The nurse assigned to him took the initial vital sign and obtained a blood pressure of 136/76 mmHg, pulse rate of 96 beats per minute and temperature of 101°F (38.3°C). During the interview the nurse noted that the client has a history of hyperlipidemia and alcohol abuse. 33. The client is prescribed to have a nasogastric tube insertion. Prior to the procedure the nurse explains its purpose to the client. Which among the following is the most appropriate statement the nurse should make? A. “It empties the stomach of fluids and gas.” B. “It prevents spasm of the sphincter of Oddi.” C. “It prevents air from forming in the small and large intestine.” D. “It removes bile from the gall bladder.” 34. Which among the following is the most reliable method of checking the placement of the nasogastric tube? A. Assessing the patient’s respiration and skin color. B. Inserting the end of the tube in water and checking for bubbling. C. Aspirating gastric contents with a syringe and checking ph. TOP RANK REVIEW ACADEMY, INC. Page 3 | 9