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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

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