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D. Rise bed rails 25. Because of the client?pleural effusion and advanced lung disease , the nurse frequently listens to the client's breath sounds . What would the nurse expect to hear when assessing the breath sounds? A. Wheezing in the upper lobes B. A friction rub posterior to the affected area C. Increased sounds over the involved area D. Decreased sounds over the involved area 26. An adult has a chest drainage system . Several hours after the chest tube was inserted the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling? A. The client's lungs have expanded. B. There is an obstruction in the tubing coming from the client. C. There is a mechanical problem in the suction control chamber D. Air is leaking into the drainage apparatus. 27. A 79-year-old client was admitted to the hospital with a diagnosis of pneumonia . The client has dyspnea. The client's temperature was 102^circ F , respiration was 28 breaths per minute, and pulse was 90 beats per minute. Bed rest was ordered for this client primarily to __ A. Promote thoracic expansion. B. Prevent the development of atelectasis. C. Decrease work of breathing. D. Prevent other infections. 28. An adult patient is admitted with chronic obstructive pulmonary disease (COPD). The ward nurse notes that he has neck vein distention and slight peripheral edema The nurse continues frequent assessments because she/he knows that these signs indicate the onset of which of the following? A. Pneumothorax C. Cardiogenic shock B. Cor pulmonale D. Left-sided heart failure

19. A 6-year-old child with a congenital heart disorder is admitted with congestive heart failure . Digoxin 0.12 mg is ordered for the child. The bottle contains 0.05 mg of digoxin in 1 mL of solution. Which of the following amounts should the nurse administer to the child? A. 1.2 ml C. 4.2 ml B. 2.4 ml D. 3.5 ml 20. Which of the following position is used while administering enema for a patient? A. Lithotomy position B. High fowlers position C. Sim's position D. Lateral position 21. Which of the following terms denotes absence or failure to produce urine? A. Anuria C. Retention B. Oliguria D. Dysuria 22. Which of the following is not a common feature to all types of cancer? A. Abnormal cellular growth B. Capacity to invade other tissues C. Capacity to spread to distant organs D. Regulated growth of cells 23. Nurse Meti is caring for a COPD patient at HFSUH in the male medical ward . She teaches him about coughing and breathing exercise. The importance of doing this exercise is: A. To enhance the expelling of mucous B. To monitor respiratory rate C. To identify the sign of respiratory distress D. For safe mouth care 24. For respiratory disorder patients with a nursing diagnosis, of'ineffective airway clearance related to high mucus production which of the following is the correct nursing intervention? A. Facilitate drainage of oral secretion B.Administer ordered antibiotics C. Administer antipain D. Rise bed rails

19. A 6-year-old child with a congenital heart disorder is admitted with congestive heart failure . Digoxin 0.12 mg is ordered for the child. The bottle contains 0.05 mg of digoxin in 1 mL of solution. Which of the following amounts should the nurse administer to the child? A. 1.2 ml C. 4.2 ml B. 2.4 ml D. 3.5 ml 20. Which of the following position is used while administering enema for a patient? A. Lithotomy position B. High fowlers position C. Sim's position D. Lateral position 21. Which of the following terms denotes absence or failure to produce urine? A. Anuria C. Retention B. Oliguria D. Dysuria 22. Which of the following is not a common feature to all types of cancer? A. Abnormal cellular growth B. Capacity to invade other tissues C. Capacity to spread to distant organs D. Regulated growth of cells 23. Nurse Meti is caring for a COPD patient at HFSUH in the male medical ward . She teaches him about coughing and breathing exercise. The importance of doing this exercise is: A. To enhance the expelling of mucous B. To monitor respiratory rate C. To identify the sign of respiratory distress D. For safe mouth care 24. For respiratory disorder patients with a nursing diagnosis, of'ineffective airway clearance related to high mucus production'which of the following is the correct nursing intervention? A. Facilitate drainage of oral secretion B. Administer ordered antibiotics C. Administer antipain D. Rise bed rails 25. Because of the client's pleural effusion and advanced lung disease, the nurse frequently listens to the client's breath sounds . What would the nurse expect to hear when assessing the breath sounds? A. Wheezing in the upper lobes B. A friction rub posterior to the affected area C. Increased sounds over the involved area

11. A patient who had undergone abdominal surgery experienced wound evisceration . Which of the following is the most appropriate immediate nursing action? A. Cover the wound with sterile gauze moistened with sterile normal saline. B. Cover the wound with sterile dry gauze. C. Cover the wound with water-soaked gauze. D. Leave the wound uncovered and pull the skin edges together 12. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature? A. Oral C. Heat sensitive tape B. Axillary D. Rectal 13. Mr. Ibrahim has a fever of 38.50C. It increases suddenly at around 40 Degrees and go back to 38.5 Degree 6 times today in a typical pattern what kind of fever is Mr . Ibrahim having? A. Relapsing C. Remittent B . Intermittent D. Constant 14. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? A. Using sterile forceps . rather than sterile gloves , to handle a sterile item B. Touching the outside wrapper of sterilized material without sterile gloves C. Placing a sterile object on the edge of the sterile field D. Pouring out a small amount of solution (15 to 30 ml)before pouring the solution into a sterile container 15. All of the following measures are recommended to prevent pressure ulcers except: A. Massaging the reddened are with lotion B. Using a cotton or air ring C. Adhering to a schedule for positioning and turning D. Providing meticulous skin care 16. Which of the following steps of instrument processing is the correct one? A. Cleaning -Decontaminat ion-Sterilization -Cooling B. Cooling -Decontaminatio n-Cleaning -Sterilization C Decontaminatior -Cleaning -Cooling -Sterilization D . Decontamination-Cleaning -Sterilization-Cooling 17. The mid-DEL .TOID injection site is seldom used for I.M . injections because it: A.Accommodate only 2 ml or less B. Does not readily parenteral medication C. Bruises too easily D. Can be used only when the patient is lying down 18. A client is to receive 3.000 mL of 0.9% NaCl IV in 24 hours.The intravenous set delivers 15 drops per milliliter. The nurse should regulate the flow rate, so that the client receives how many drops of fluid per minute? A. 21 C. 31 B. 28 D. 42

6. The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular Broncho vesicular, and bronchial breath sounds . The nurse should distinguish between these normal breath sounds on what basis? A. Their location over a specific area of the lung B. The volume of the sounds C. Whether they are heard on inspiration or expiration D. Whether or not they are continuous breath sounds 7. The nurse is assessing the skin conditions of the patients and the nurse notes that the hypertrophic scarring because of excess collagen formation; raised and irregular overgrows of the original wound. The conditions would likely; A. Petechiae B. Ecchymosis C. Keloid D. Fibrosis 8. Which of the following theorist decreased mortality by improving sanitation in the battlefields. resulting in a decrease in illness and infection? A. Dorothea Orem C. Martha Rogers B. Florence Nightinga D. Virginia Henderson 9. Which of the following degree of needle insertion is used for the intradermal route of drug administration? A. 45^0 B. 10^0 to 15^0 C. 90^circ D. 25^0 10. A nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32breath/minute elevated blood pressure , and fatigue. Which nursing diagnosis is the priority for this client? A. Ineffective Coping B. Impaired nutrition C. Anxiety D. Ineffective Breathing Pattern