Tiêu đề PNLE 1.pdf ✅

PNLE I for Foundation of Professional Nursing Practice 1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is: A. The physician’s orders. B. The action of a clinical nurse specialist who is recognized expert in the field. C. The statement in the drug literature about administration of terbutaline. D. The actions of a reasonably prudent nurse with similar education and experience. 2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? A. I.V B. I.M C. Oral D. S.C 3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record? A. “Digoxin .1250 mg P.O. once daily” B. “Digoxin 0.1250 mg P.O. once daily” C. “Digoxin 0.125 mg P.O. once daily” D. “Digoxin .125 mg P.O. once daily” 4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority? A. Ineffective peripheral tissue perfusion related to venous congestion. B. Risk for injury related to edema. C. Excess fluid volume related to peripheral vascular disease. D. Impaired gas exchange related to increased blood flow. 5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? A. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. B. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. D. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: A. Assess temperature frequently. B. Provide diversional activities. C. Check circulation every 15-30 minutes. D. Socialize with other patients once a shift. 7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to: A. Prevent stress ulcer B. Block prostaglandin synthesis C. Facilitate protein synthesis. D. Enhance gas exchange 8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? A. Increase the I.V. fluid infusion rate B. Irrigate the indwelling urinary catheter C. Notify the physician D. Continue to monitor and record hourly urine output 9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? A. “My ankle looks less swollen now”. B. “My ankle feels warm”. C. “My ankle appears redder now”. D. “I need something stronger for pain relief” 10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? A. Hypernatremia B. Hyperkalemia C. Hypokalemia D. Hypervolemia

24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse? A. Notify the physician. B. Place the client on the left side in the Trendelenburg position. C. Place the client in high-Fowlers position. D. Stop the total parenteral nutrition. 25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is: A. Autocratic. B. Laissez-faire. C. Democratic. D. Situational 26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution? A. .5 cc B. 5 cc C. 1.5 cc D. 2.5 cc 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 deliver this amount is: A. 50 cc/ hour B. 55 cc/ hour C. 24 cc/ hour D. 66 cc/ hour 28.The nurse is aware that the most important nursing action when a client returns from surgery is: A. Assess the IV for type of fluid and rate of flow. B. Assess the client for presence of pain. C. Assess the Foley catheter for patency and urine output D. Assess the dressing for drainage. 29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? A. BP – 80/60, Pulse – 110 irregular B. BP – 90/50, Pulse – 50 regular C. BP – 130/80, Pulse – 100 regular D. BP – 180/100, Pulse – 90 irregular 30.Which is the most appropriate nursing action in obtaining a blood pressure measurement? A. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart. B. Measure the client’s arm, if you are not sure of the size of cuff to use. C. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart. D. Document the measurement, which extremity was used, and the position that the client was in during the measurement. 31.Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process? A. Assessment B. Evaluation C. Implementation D. Planning and goals 32.Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs? A. Diagnostic test results B. Biographical date C. History of present illness D. Physical examination 33.In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use: A. Trochanter roll extending from the crest of the ileum to the midthigh. B. Pillows under the lower legs. C. Footboard D. Hip-abductor pillow 34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? A. Stage I B. Stage II C. Stage III D. Stage IV 35.When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed A. Second intention healing