FUNDAMENTALS of NURSING Situation: The nurse has been asked to administer injection via Z-TRACT technique. 1.

The nurse prepares an IM injection for an adult client using the Z-tract technique. 4ml is to be administered to the client. Which of the following site will you choose? A. deltoid B. rectus femoris C. ventrogluteal D. vastus lateralis 2. In infants 1 year old and below, which of the following is the site of choice for IM injection? A. deltoid B. rectus femoris C. ventrogluteal D. vastus lateralis 3. In order to decrease discomfort in Z-tract administration the nurse should: A. pierce the skin quickly and smoothly in a 90 angle B. inject the medication readily at around 10 mins/milliliter C. pull back the plunger and aspirate to make sure that the needle did not hit any blood vessel D. pierce the skin slowly and carefully at a 90 angle 4. After injection using the Z-tract technique, the nurse should know that she needs to wait for a few seconds before withdrawing the needle to allow the medication to disperse into the muscle tissue thus decreasing the clients discomfort. How many seconds should the nurse wait before withdrawing the needle? A. 2 secs B. 5 secs C. 10 secs D. 15 secs 5. The rationale in using the Z-tract technique in an intramuscular injection: A. decrease the leakage of the discoloring and irritating medication into the subcutaneous tissue B. it will allow faster absorption of the medication C. the Z-tract technique prevents irritating the muscle D. it is much more convenient for the nurse Situation: A client was rushed into the emergency room and you are his attending nurse. You are performing a vital sign assessment. 6. All of the following are correct methods in assessment of the blood pressure, EXCEPT: A. take the blood pressure reading on both arms for comparison B. listen to and identify the phases of Korotkoffs sound C. pump the cuff to around 50mmHg above the port, where the pulse is obliterated D. observe procedures for infection control 7. After a few hours in the ER, the client is admitted to the ward with an hourly order of monitoring blood pressure. The nurse finds out that the cuff is to narrow and this will cause the BP reading to be: A. inconsistent C. higher than what the reading should be B. low systolic and high diastolic D. lower than what the reading should be. 8. Through the clients health history, you gather that the patient smokes and drink coffee. When taking the blood pressure of a client who recently smoke or drank coffee, how long should the nurse wait before taking the clients blood pressure for accurate reading? A. 15 minutes B. 30 minutes C. 1 hour D. 5 minutes 9. The nurse finds it necessary to recheck the blood pressure reading. In case of such re-assessment, the nurse should wait for how long? A. 15 seconds B. 1 to 2 minutes C. 30 minutes D. 15 minutes 12. If the arm is said to be elevated when taking the BP, it will create a: A. false high reading C. true-false reading B. false low reading D. undetermined 13. You are to assess the temperature of the client the next morning and found out that he has just eaten ice cream. In such event, the nurse should wait for a period of ________ before assessing the clients oral temperature. A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes 14. When auscultating the clients blood pressure, the nurse hears the following: From 150mmHg to 130mmHg: SILENCE; then a thumping sound continuing down to 110mmHg; muffled sound continuing down to 80mmHg and then silence. What is the clients blood pressure? A. 130/80mmHg B. 150/100mmHg C. 100/80mmHg D. 150/80mmHg 15. In a client with a previous BP of 130/80mmHg four hours ago, how long will it take to release the BP cuff to obtain an accurate reading? A. 10-20 seconds B. 30-45 seconds C. 1-1.5 minutes D. 3-3.5 minutes 28. Dr. Reynolds prescribed 5mL of medication to be given by deep IM for a 40-year-old female. Emmie Stevenson, who is 5 4 tall and weighs 135 lbs. which of the ff is the most appropriate method of administration? A. a tuberculin syringe, G25- G25, to 5/8in needle B. Two 3mL-syringe, G20-G23, 1 in needle C. Two 2mL-syringe, G25, 2/8in needle D. Two 2mL-syringe, G20-G23, 1in needle 29. The nurse, Kent, is to administer a tuberculin test to Pulot, a 22-year-old female, who is 6 feet tall and weighs 180 lbs. which of the ff is the most appropriate for the nurse to use? A. a tuberculin syringe, G25- G27, to 5/8in needle B. Two 3mL-syringe, G20-G23, 1 in needle C. Two 2mL-syringe, G25, 2/8in needle D. Two 2mL-syringe, G20-G23, 1in needle

30. If a fever of a patient fluctuates from 38 to 40 Celsius, he is said to have what type of fever? A. Intermittent B. Remittent C. Constant D. Relapsing 31. When taking a patients blood pressure, the nurse opens the pressure valve knob and the mercury drops quickly. The nurse should: A. Remove the cuff and send the sphygmomanometer for repair. B. Squeeze the air out of the cuff and try again C. Wait for 2 minutes before pumping up the cuff D. Check the tubing if there are leaks 32. Kussmauls responses are characterized by the bodys efforts to blow off excessive CO2 with: A. abnormally deep rapid inhalations B. an excessive effort to inhale and exhale C. a rate of breathing that is slow and regular D. alternate periods of apnea and deep rapid breathing 33. To straighten the ear canal of a 2-year-old child, you must: a. pull the external ear upward, backward c. pull the external ear downward, forward b. pull the external ear downward, backward d. pull the external ear upward, forward 34. Which action is unique when administering medication via Z-tract method? A. the skin is pulled laterally before needle insertion B. injection sites are rotated along a Z on the abdomen C. an air lock is established behind the bolus of medication D. a Z is formed when dividing the buttocks into quadrants 35. Which statement would indicate that the patient needed further teaching regarding care of the eyes and eye medications? A. Excess medications on the eyelid can be wiped away. B. I should gaze downward while instilling the eye drops C. I should place one drop of medication inside my lower eyelid D. The risk of transmitting infection from one eye to the other eye is high 36. What should the nurse do when blood appears in the hub of the needle while aspirating an IM injection? A. removes the syringe and attaches a new needle B. discards the syringe and prepares a new medication C. interrupts the procedure and notifies the physician D. withdraws the needle slightly and injects the solution 37. The nurse would recognize that further teaching was needed about the administration of eye drops when the patient says, I should.: A. wipe my eye moving from the outer toward my nose. B. hold the dropper about 1/2in above my eye. C. close my eyes after putting the drops in my eye. D. put the fluid in a pocket in the lower lid. 38. What should the nurse do first when injecting an intravenous medication via an already existing IV line? A. select the port closest to the needle entry site B. pinch tubing above the port being used C. determine patency of the intravenous line D. clean the injection port with an antiseptic 39. The nurse recognizes that the patient understand the teaching about how to self- administer a rectal suppository when the patient: A. bears down during insertion of the suppository B. requests sterile gloves to perform the procedure C. allows the suppository to warm in room temperature D. inserts the suppository immediately after its removal from the refrigerator 40. What is the most important for the nurse to do when administering a topical medicated cream to a patients skin? A. use medical aseptic technique when applying the medication B. wash the area before administering the medication C. pat the medication onto the surface of the skin D. apply a moderate layer of the medication 41. The correct Z-tract injection of iron is: A. pull the skin at site of injection down B. inject deep IM Situation: Administering Medication 44. When administering oral liquid medication to a 6-month-old infant, the nurse would: A. mix the drug in the infants formula and offer with the next feeding B. sweeten the drug with honey and give from a teaspoon C. quickly squirts the drug from a syringe to the back of the mouth D. quickly squirts the drug from a syringe into the cheek pocket 45. An infant who weighs 2.27 lbs (5 kgs) is to receive 750mg of antibiotic in a 24-hour period. The liquid antibiotic comes in a concentration of 125mg per 5mL. if the antibiotic is to be given 3x each day, how many mL would the nurse administer with each dose? A. 2 B. 5 C.6.25 D.10 C. massage the skin D. pull the skin tight

46. A nurse observes a mother administering eardrops to her 4-year-old child who has acute right-sided otitis media. Which of the ff actions if taken by the mother indicates the administration was performed correctly? A. removing wax in the affected ear with a cotton swab prior to the procedure B. pulling the pinna of the affected ear upward and back when administering the drug C. placing the ear drop container under cool, running water prior to the procedure D. placing the child in a recumbent position for several minutes after the procedure 47. A nurse is providing discharge teaching to the family of an elderly patient who is confused and is taking several oral medications. Which of the ff instructions should be given priority? A. administer medication with meals C. supervise the patients medication administration B. withhold the medication the patient refuses D. allow the patient to self medicate when possible

Situation: Vital signs taking 52. Which of the ff temperature is a few degrees lower than oral temperature? A. Rectal temp. B. Axillary temp. C. Core temp. D. tympanic membrane temp. 53. Where should the oral thermometer be placed? A. In between the teeth of the client, above the tongue B. In between the teeth of the client, below the tongue C. Posterior sublingual pocket D. Lateral to the tongue at buccal mucosa 54. The usual position of the client when taking the rectal temperature is in the? A. Supine position C. Dorsal recumbent position B. Lateral position with upper leg flexed D. Prone position with legs slightly flexed 55. The depth of insertion of a rectal thermometer is? A. 0.5 in B. 1.0 in C. 1.5 in D. 2.0 in

56. When you took your adult clients temperature at 8:00 am using an oral thermometer, the result is 36.1C (97.2F). All the other vital signs are within normal range. What would you do next? A. Wait for 15 minutes and retake it B. Check what time the clients temperature was taken C. Retake it using a different thermometer D. Chart the temperature: it is normal 57. A pulse is normally palpitated by applying moderate pressure on the site using: A. One finger B. two fingers C. three fingers D. four fingers 58. Which of the following pulse sites when assessed necessitates the used of the bell-shaped diaphragm of the stethoscope? A. Carotid pulse B. apical pulse C. brachial pulse D. non of the above 59. If the client has been physically active, which action would the nurse consider before taking the pulse rate? A. Ask the client for any medication he/she has taken that could affect his heart rate B. Ask the client to sit down C. Wait for 10-15 minutes until the client has rested D. Give the client something to drink 60. The apical pulse is also known as the: A. Point of maximal impulse B. Heart beat C. S1 D. S2

61. Mr. Palencia visited the health center for the first time to have his BP taken. The nurse decided to take his BP on both arms. Which of the ff statements regarding BP taken on both left and right arm is CORRECT? A. The BP measurements taken on both arms should be equal B. A difference of 10mmHg between the arm is acceptable C. There is no need to take the BP measurement in both arms if you are sure that your findings in one arm is correct D. The arm found to have a lower BP should be used for subsequent examinations. 62. Which of the ff statements about preliminary palpatory systolic pressure is NOT CORRECT? A. It is the initial estimate that tells the nurse the maximal pressure to which the manometer should be elevated in subsequent determinations B. It prevents underestimation of the systolic pressure or overestimation of the diastolic pressure should an ausculatory gap occur C. It prevents the occurrence of the ausculatory gap D. All of the above 63. When taking the respiratory rate of an infant, the ff are necessary EXCEPT: A. Wait for the infant to stop crying before taking the respirations B. Place the hand gently on the infants abdomen to feel its rise and fall during respirations. C. Count respirations only after taking the pulse. D. Count the respirations for one full minute 64. Which of the following is NOT a purpose of assessing respirations? A. To acquire baseline data against which future measurements will be measured B. To assess respirations before the administration of medication such as morphine

C. To monitor respirations following the administration of a general anesthetic D. To monitor client at risk for GIT problems. Situation: Administering Medications 65. Administering of parenteral medications require the use of needles with varying gauges. Which of the ff statements below regarding needle gauge is CORRECT? A. The needle gauge varies from #10 to #18 B. The larger the gauge number, the smaller the diameter of the shaft C. The larger the gauge number, the larger the diameter of the shaft D. Needle gauge varies only from #22 to #24 66. To prevent needlestick injuries, the ff should be observed, EXCEPT: A. Use of one-handed scoop method when recapping the needle B. Never break or bend the needles before disposal. C. Use puncture-proof disposal containers to dispose of uncapped needles and sharps D. Use a two-handed technique when recapping needles to ensure proper capping. 67. When breaking an ampoule neck, the nurse should: A. Break off the top by bending it toward herself B. Break off the top by bending it away from herself C. Break off the top in any direction he/she prefers D. Ampoule necks should be filed until they break off 68. This injection site should not be used for children under three years of age. A. Vastus lateralis site C. Ventrogluteal site B. Dorsogluteal site D. deltoid site 69. This injection site is the site of choice for intramuscular injections for infants who are 7 months younger? A. Vastus lateralis site C. Ventrogluteal site B. Dorsogluteal site D. deltoid site 70. The following should be observed when administering rectal suppository, EXCEPT: A. Position the client in supine position. B. Lubricated the smooth rounded end of the suppository. C. Avoid embedding the suppository in feces D. The suppository should be retained by the client for at least 30 to 40 minutes 71. The nurse is to administer a tuberculin test to a 23-year-old male, who is 6 feet tall and weighs 180 lbs. What is the appropriate syringe size, needle gauge and needle length in the situation? A. a tuberculin syringe, G25- G27, to 5/8in needle B. Two 3mL-syringe, G20-G23, 1 in needle C. Two 2mL-syringe, G25, 2/8in needle D. Two 2mL-syringe, G20-G23, 1in needle Situation: Pain Management 72. A client has arrived to the nursing unit after surgery. The nurse would most likely to obtain which of the ff information as a priority assessment? A. Vital signs B. Pain intensity C. Location of pain D. Pain history 73. A client who describes his pain as a 6 on scale of 1 to 10 is having: A. Severe pain B. mild pain C. very severe pain D. moderate pain