1. The patient with the highest percentage of body weight as water is: a. Johnny, 78 years old. b. Peter, 45 years old. c. Lucy, 16 years old. d. Robert 3 days old. 2. Lisa, 35-year-old female client, admitted with a diagnosis of dehydration secondary to 3-day history of diarrhea is receiving an IV of 0.9 NS at 120 ml/hour. In 2 ½ hours the client received 390 ml. The IV infusion is said to be a. 45 minutes ahead. b. 45 minutes behind. c. 15 minutes behind. d. 15 minutes ahead. 3. If the potassium level of the patient is 5.6. The PN would do which of the following: a. Inform the nurse in charge. b. Observe the patient. c. Monitor the patient’s vital signs. d. Inform the physician. 4. The practical nurse’s assessment indicating dehydration would include signs and symptoms of a. Clubbing of fingers and toes b. Patient complains of feeling cold and chilly c. Dry mucous membrane; decreased urine output d. Patient has a fever 5. What is the most appropriate way to take the temperature of an 18-month old with severe diarrhea? a. Rectal b. Oral c. Axillary d. Do not take the temperature 6. Joe, 69-year-old client, is on IV therapy. The PN assigned to him has noticed that he receives 300 ml of fluids in an hour. The most appropriate initial action by the PN would be to a. Check the client`s apical pulse and determine if it went lower than his normal pulse b. Maintain the client in a supine position c. Administer oxygen 2 d. Place the client in an upright position 7. The following are signs and symptoms of blood transfusion reaction: a. Pain at the intravenous site, rashes all over the body, palpitations b. Dysphagia, diplopia, hematuria c. Hypertension, back pain, confusion d. Flank pain, hypotension, fever 8. After a successful surgery, the client was noted to have a urine output of 800 ml. Four hours later, she voided another 400 ml. Based on the PN’s findings, the most appropriate nursing action would be which of the following? a. Consider this as normal finding. b. Collect urine sample for urinalysis. c. Record the finding in the progress note. d. Consult the nurse in charge. 9. The PN who is assigned to the patient receiving blood transfusion is aware that one of the following is essential: a. Expect the use a blood warmer during blood transfusion. b. Expect the blood, one unit, to be transfused in 4 to 5 hours. c. Closely monitor the child for possible blood transfusion reaction during the first few minutes of blood transfusion. d. Monitor the child’s vital signs every 30 minutes. 10. Due to prolonged bedrest, Mrs. Cox is very prone to skin breakdown. Which of the following nursing action will promote the patient’s skin integrity? a. Massage the patient’s bony prominences with cream. b. Apply liberal amount of talcum powder and alcohol to the patient’s dry skin. c. Turn the patient every 2 hours and avoid wrinkles on the bedsheets. d. Wash the patient’s skin daily with soap and warm water and keep it dry at all times. 11. The patient with asthma received bronchodilator and an IV infusion was started. Because the patient is restless and confused, which of the following methods would be best for the PN to use in taking his vital signs? a. Take an apical pulse and a rectal temperature. b. Take radial pulse and an oral temperature. c. Take a pedal pulse and a rectal temperature. d. Take a radial pulse and a rectal temperature. Terry has vomiting and diarrhea. He is dehydrated. 3 12. Which of the following nursing intervention is most appropriate for Terry’s condition? a. Weigh patient daily, monitor for bulging fontanel, and poor skin turgor. b. Monitor for sunken fontanel, increased apical pulse, and decreased urine output. c. Check for poor skin turgor, IV fluids, reversed isolation. d. Weigh patient twice daily, cuddle the baby when crying, IV fluids. 13. Which of the following assessment accurately determine fluid loss in a 78-year- old male patient with dehydration? a. Urine specific gravity is lesser than normal. b. Dry mucus membrane and delayed capillary refill. c. Loose skin and poor skin turgor. d. Pull the skin around the chest and weigh daily. 14. A 72-year- old mother, taken cared by her daughter at home, has incontinence episodes. Which of the following health teachings provided by the PN to the daughter best promote skin integrity? a. Wash the patient’s perineum with soap and water after each incontinence episode. b. Instruct the daughter to wash and apply skin barrier and incontinent pad. c. Encourage the daughter to frequently reposition the patient. d. Teach the daughter to wash, clean, dry, apply skin barrier, pads and reposition the patient. 15. A 50-year-old woman is admitted for hip repair and splenectomy following a motor vehicle accident. Three hours post-op her LOC is decreased. VS are BP 82/56; HR 120; RR 28; skin cool and clammy; no c/o SOB; lungs sounds clear; u/o 20 ml/hour; T 36.5°C; WBCs 9000. Based on this information, what condition appears to be developing? a. LV failure b. Neurogenic shock c. Septic shock d. Hypovolemic shock 16. After a surgical procedure for cancer of the pancreas, a patient is to receive the following intravenous fluids over 24 hours: 1000 ml D5W; 0.5 liter NS; 1500 ml D5NS. In addition, an antibiotic IVPB in 50 ml D5W is ordered and given every 8 hours. Total fluid intake of the patient for 24 hours will be: a. 3150 ml b. 3200 ml c. 3650 ml d. 3750 ml 4 17. The patient has been receiving 2500 ml of IV fluid and 300 to 400 ml of oral intake daily for 2 days. The patient’s urine output has been decreasing and now has been less than 40 ml per hour for the past 3 hours. The PN should immediately: a. Catheterize the patient to empty the bladder. b. Assess breath sounds and obtain the patient’s vital signs. c. Check for dependent edema and continue to monitor I/O. d. Decrease the IV flow rate and increase oral fluids to compensate. 18. If a patient presents with diarrhea, it’s essential to monitor his: a. Blood Pressure b. Fluid and electrolyte balance c. Temperature d. Blood glucose level 19. A patient who is receiving blood transfusion develops hemolytic transfusion reaction. After the blood transfusion was stopped, the next appropriate action would be: a. Run the IV NS. b. Send the remaining blood to the lab. c. Call the physician ASAP. d. Assess the patient’s vital signs. 20. In blood transfusion, what is the side effect of priming with D5W instead of normal Saline? a. high fever b. hemolysis c. blocked tube d. edema 21. A client has just received 2 units of packed cells for anemia. What instruction should the practical nurse reinforced when the transfusion is discontinued. a. Report any unusual manifestations. b. Maintain fluid intake of 3,000 ml. c. Limit ambulation to 2 hours following the transfusion. d. Measure fluid intake and output 22. A 25-year-old patient has an advance directive written 3 years ago that he does not want any blood transfusion in any circumstance. The PN who receives an order for blood transfusion will do which of the following? a. Do not hang the blood; take the patient’s card to the ordering physician. b. Explore the possibility of autologous blood transfusion to the patient. c. Speak to the patient’s family and get a permission to transfuse the blood. d. Ask the doctor to explain to the patient the necessity of blood transfusion. 5 23. Following the transfusion of one unit of RBC, the nurse prepares to administer another unit. Which of the following actions will not be appropriate for the PN to take initially? a. Check the type and cross match with another nurse. b. Leave the blood at room temperature for at least 30 minutes before infusing. c. Flush the tubing with normal saline. d. Monitor the patient very closely during the 15 minutes of the transfusion. 24. The patient who sustains gunshot wound requires 2 units of packed cells and a loading dose of IV antibiotics. Appropriate nursing action taken by the PN was: a. Administer the IV antibiotic first followed by blood transfusion. b. Start the blood transfusion and piggyback the antibiotics. c. Administer the antibiotic following blood transfusion. d. Administer the antibiotic and piggyback the packed cells. 25. The patient complains of dry cough two hours after blood transfusion has been started. The most appropriate nursing action taken by the PN include: a. stop the blood transfusion b. stop the IV infusion c. observe the patient d. continue the blood transfusion 26. While monitoring blood transfusion, the PN assesses the vital signs and notes that the client’s temperature has gone from 37.2°C to 38.5° C. The client is experiencing no other symptoms. Which of the action taken by the PN is appropriate? a. Continue monitoring for other symptoms b. Notify the team leader to discontinue the transfusion c. Notify the physician immediately d. Encourage the client to drink extra fluids 27. Mrs. Schwartz, 70 years old, was admitted to the medical unit with a diagnosis of anemia. She has a history of chronic congestive heart failure. Two hours into her blood transfusion, Mrs. Schwartz develops a dry cough. What should the PN do? a. Discontinue the transfusion, sit her upright, monitor vital signs closely and report b. Continue the transfusion, assess her breathing, collect sputum for culture and sensitivity and document c. Stop the transfusion, have her deep breathe and cough, check her oxygen saturation and document d. Slow the flow rate of the blood transfusion, monitor vital signs, report and document 6 28. Prior to the blood transfusion, Mr. Beer is given Benadryl. The PN recognizes that the purpose of this measure is to: a. Sedate him for the transfusion b. Prevents hemolysis of the blood c. Permit a more rapid infusion of the blood d. Minimize a possible transfusion reaction 29. This is a 45-year-old patient who lost large amount of blood due to gunshot wound (GSW) on the thigh and abdomen. The patient develops hypotension while receiving transfusion. Which of the following other symptoms, if seen in this patient, would be most significant in terms of realizing that a potential complication is occurring? a. Shortness of breath b. Back pain c. Hematuria d. Proteinuria 30. What position do you place the patient in shock? a. Trendelenburg position b. Semifowler c. High fowlers d. Sim’s position 31. When recording a patient’s fluid intake, the nurse would include: a. 120 cc of juice, 1 cup of mashed potatoes, and 700 cc IV solution b. 500 cc of tube feeding, 60 cc of lactulose by mouth, and 750 cc IV solution c. 1 hamburger, 1/2 cup of carrots, and 1 cup of ice cream d. 750 cc IV solution, 1 cup of ice cream, and 1 cup of tapioca pudding 32. The client is receiving infusions therapy of normal saline (0.9%) in the left forearm. On assessment, the PN notes that the solution is not dripping in the drip chamber. What should the PN do? a. Check the site, look for obstruction of tubing, and reposition arm. b. Check the site, reposition arm, and raise the solution container. c. Close off drip chamber, reposition arm, and regulate flow clamp. d. Close off drop chamber, raise the solution bag, and reposition. 33. Which of the following data are most important for the practical nurse to have when caring for a client with a 1V infusion at home? a. 1V infusion therapy prescribed; appropriate infusion control device for this client. b. Client’s diagnosis; response to infusion therapy in the hospital. c. Client’s ability to ambulate: available home storage area for equipment. d. Home floor plan to accommodate need for medical asepsis: caregiver support.