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Home  Practice Exams  Philippine Nursing Licensure Exam (PNLE)  PNLE III Nursing Practice

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PNLE III Nursing Practice
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The scope of this Nursing Test III is parallel to the NP3

NLE Coverage:

Medical Surgical Nursing

1. The nurse is going to replace the Pleur-O-Vac

attached to the client with a small, persistent left upper
lobe pneumothorax with a Heimlich Flutter Valve. Which RELATED
POSTS
of the following is the best rationale for this?
PNLE :
Maternal

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 Maternal
A. Promote air and pleural drainage and
B. Prevent kinking of the tube Child
Health
C. Eliminate the need for a dressing Nursing …
D. Eliminate the need for a water-seal drainage   0

PNLE I
2. The client with acute pancreatitis and Xuid volume
for
deYcit is transferred from the ward to the ICU. Which of Foundation
the following will alert the nurse? of
Nursing
  0
A. Decreased pain in the fetal position
B. Urine output of 35mL/hr PNLE:
C. CVP of 12 mmHg Community
Health
D. Cardiac output of 5L/min Nursing
Exam
3. The nurse in the morning shift is making rounds in the 2
  0
ward. The nurse enters the client’s room and found the
client in discomfort condition. The client complains of PNLE:
stiffness in the joints. To reduce the early morning Community
stiffness of the joints of the client,the nurse can Health
Nursing
encourage the client to: Exam
4
A. Sleep with a hot pad   0

B. Take to aspirins before arising, and wait 15 minutes

PNLE:
before attempting locomotion Community
C. Take a hot tub bath or shower in the morning Health
Nursing
D. Put joints through passive ROM before trying to
Exam
move them actively 5
  0
4. The nurse is planning of care to a client with peptic
ulcer disease. To avoid the worsening condition of the
client, the nurse should carefully plan the diet of the
client. Which of the following will be included in the diet
regime of the client?

A. Eating mainly bland food and milk or dairy products

B. Reducing intake of high-Yber foods
C. Eating small, frequent meals and a bedtime snack
D. Eliminating intake of alcohol and coffee

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 D. Eliminating intake of alcohol and coffee

5. The physician has given instruction to the nurse that

the client can be ambulated on crutches, with no weight
bearing on the affected limb. The nurse is aware that the
appropriate crutch gait for the nurse to teach the client
would be:

A. Tripod gait
B. Two-point gait
C. Four-point gait
D. Three-point gait

6. The client is transferred to the nursing care unit from

the operating room after a transurethral resection of the
prostate. The client is complaining of pain in the
abdomen area. The nurse suspects of bladder spasms,
which of the following is the best nursing action to
minimize the pain felt by the client?

A. Advising the client not to urinate around catheter

B. Intermittent catheter irrigation with saline
C. Giving prescribed narcotics every 4 hour
D. Repositioning catheter to relieve pressure

7. A client is diagnosed with peptic ulcer. The nurse

caring for the client expects the physician to order which
diet?

A. NPO
B. Small feedings of bland food
C. A regular diet given frequently in small amounts
D. Frequent feedings of clear liquids

8. The nurse is going to insert a Miller-Abbott tube to the

client. Before insertion of the tube, the balloon is tested

for patency and capacity and then deXated. Which of the

following nursing measure will ease the insertion to the

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 following nursing measure will ease the insertion to the
tube?

A. Positioning the client in Semi-Fowler’s position

B. Administering a sedative to reduce anxiety
C. Chilling the tube before insertion
D. Warming the tube before insertion

9. The physician ordered a low-sodium diet to the client.

Which of the following food will the nurse avoid to give
to the client?

A. Orange juice.
B. Whole milk.
C. Ginger ale.
D. Black coffee.

10. Mr. Bean, a 70-year-old client is admitted in the

hospital for almost one month. The nurse understands
that prolonged immobilization could lead to decubitus
ulcers. Which of the following would be the least
appropriate nursing intervention in the prevention of
decubitus?

A. Giving backrubs with alcohol

B. Use of a bed cradle
C. Frequent assessment of the skin
D. Encouraging a high-protein diet

11. The physician prescribed digoxin 0.125 mg PO qd to

a client and instructed the nurse that the client is on
high-potassium diet. High potassium foods are
recommended in the diet of a client taking digitalis
preparations because a low serum potassium has which
of the following effects?

A. Potentiates the action of digoxin

B. Promotes calcium retention
C. Promotes sodium excretion

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 C. Promotes sodium excretion
D. Puts the client at risk for digitalis toxicity

12. The nurse is caring for a client who is transferred

from the operating room for pneumonectomy. The nurse
knows that immediately following pneumonectomy; the
client should be in what position?

A. Supine on the unaffected side

B. Low-Fowler’s on the back
C. Semi-Fowler’s on the affected side
D. Semi-Fowler’s on the unaffected side

13. A client is placed on digoxin, high potassium foods

are recommended in the diet of the client. Which of the
following foods willthe nurse give to the client?

A. Whole grain cereal, orange juice, and apricots

B. Turkey, green bean, and Italian bread
C. Cottage cheese, cooked broccoli, and roast beef
D. Fish, green beans and cherry pie

14. The nurse is assigned to care to a client who

undergone thyroidectomy. What nursing intervention is
important during the immediate postoperative period
following a thyroidectomy?

A. Assess extremities for weakness and Xaccidity

B. Support the head and neck during position changes
C. Position the client in high Fowler’s
D. Medicate for restlessness and anxiety

15. What would be the recommended diet the nurse will

implement to a client with burns of the head, face, neck
and anterior chest?

A. Serve a high-protein, high-carbohydrate diet

B. Encourage full liquid diet

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 B. Encourage full liquid diet
C. Serve a high-fat diet, high-Yber diet
D. Monitor intake to prevent weight gain

16. A client with multiple fractures of both lower

extremities is admitted for 3 days ago and is on skeletal
traction. The client is complaining of having dijculty in
bowel movement. Which of the following would be the
most appropriate nursing intervention?

A. Administer an enema
B. Perform range-of-motion exercise to all extremities
C. Ensure maximum Xuid intake (3000ml/day)
D. Put the client on the bedpan every 2 hours

17. John is diagnosed with Addison’s disease and

admitted in the hospital. What would be the appropriate
nursing care for John?

A. Reducing physical and emotional stress

B. Providing a low-sodium diet
C. Restricting Xuids to 1500ml/day
D. Administering insulin-replacement therapy

18. Mr. Smith is scheduled for an above-the-knee

amputation. After the surgery he was transferred to the
nursing care unit. The nurse assigned to him knows that
72 hours after the procedure the client should be
positioned properly to prevent contractures. Which of
the following is the best position to the client?

A. Side-lying, alternating left and right sides

B. Sitting in a reclining chair twice a day
C. Lying on abdomen several times daily
D. Supine with stump elevated at least 30 degrees

19. A client is scheduled to have an inguinal

herniorraphy in the outpatient surgical department. The

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 herniorraphy in the outpatient surgical department. The
nurse is providing health teaching about post surgical
care to the client. Which of the following statement if
made by the client would reXect the need for more
teaching?

A. “I should call the physician if I have a cough or cold

before surgery”
B. “I will be able to drive soon after surgery”
C. “I will not be able to do any heavy lifting for 3-6
weeks after surgery”
D. “I should support my incision if I have to cough or
turn”

20. Ms Jones is brought to the emergency room and is

complaining of muscle spasms, numbness, tremors and
weakness in the arms and legs. The client was
diagnosed with multiple sclerosis. The nurse assigned
to Ms. Jones is aware that she has to prevent fatigue to
the client to alleviate the discomfort. Which of the
following teaching is necessary to prevent fatigue?

A. Avoid extremes in temperature

B. Install safety devices in the home
C. Attend support group meetings
D. Avoid physical exercise

21. Mr. Stewart is in sickle cell crisis and complaining

pain in the joints and dijculty of breathing. On the
assessment of the nurse, his temperature is 38.1 ºC.
The physician ordered Morphine sulfate via patient-
controlled analgesia (PCA), and oxygen at 4L/min. A
priority nursing diagnosis to Mr. Stewart is risk for
infection. A nursing intervention to assist in preventing
infection is:

A. Using standard precautions and medical asepsis

B. Enforcing a “no visitors” rule
C. Using moist heat on painful joints

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 C. Using moist heat on painful joints
D. Monitoring a vital signs every 2 hour

22. Mrs. Maupin is a professor in a prestigious university

for 30 years. After lecture, she experience blurring of
vision and tiredness. Mrs. Maupin is brought to the
emergency department. On assessment, the nurse notes
that the blood pressure of the client is 139/90. Mrs.
Maupin has been diagnosed with essential hypertension
and placed on medication to control her BP. Which
potential nursing diagnosis will be a priority for
discharge teaching?

A. Sleep Pattern disturbance

B. Impaired physical mobility
C. Noncompliance
D. Fluid volume excess

23. Following a needle biopsy of the kidney, which

assessment is an indication that the client is bleeding?

A. Slow, irregular pulse

B. Dull, abdominal discomfort
C. Urinary frequency
D. Throbbing headache

24. A client with acute bronchitis is admitted in the

hospital. The nurse assigned to the client is making a
plan of care regarding expectoration of thick sputum.
Which nursing action is most effective?

A. Place the client in a lateral position every 2 hour

B. Splint the patient’s chest with pillows when
coughing
C. Use humiYed oxygen
D. Offer Xuids at regular intervals

25. The nurse is going to assess the bowel sound of the

client. For accurate assessment of the bowel sound, the

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 client. For accurate assessment of the bowel sound, the
nurse should listen for at least:

A. 5 minutes
B. 60 seconds
C. 30 seconds
D. 2 minutes

26. The nurse encourages the client to wear

compression stockings. What is the rationale behind in
using compression stockings?

A. Compression stockings promote venous return

B. Compression stockings divert blood to major
vessels
C. Compression stockings decreases workload on the
heart
D. Compression stockings improve arterial circulation

27. Mr. Whitman is a stroke client and is having dijculty

in swallowing. Which is the best nursing intervention is
most likely to assist the client?

A. Placing food in the unaffected side of the mouth

B. Increasing Yber in the diet
C. Asking the patient to speak slowly
D. Increasing Xuid intake

28. Following nephrectomy, the nurse closely monitors

the urinary output of the client. Which assessment
Ynding is an early indicator of Xuid retention in the
postoperative period?

A. Periorbital edema
B. Increased speciYc gravity of urine
C. A urinary output of 50mL/hr
D. Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with
cirrhosis. Which of the following nursing assessment is

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 cirrhosis. Which of the following nursing assessment is
important to notify the physician?

A. Expanding ecchymosis
B. Ascites and serum albumin of 3.2 g/dl
C. Slurred speech
D. Hematocrit of 37% and hemoglobin of 12g/dl

30. Mr. Park is 32-year-old, a badminton player and has a

type 1 diabetes mellitus. After the game, the client
complains of becoming diaphoretic and light-
headedness. The client asks the nurse how to avoid this
reaction. The nurse will recommend to:

A. Allow plenty of time after the insulin injection and

before beginning the match
B. Eat a carbohydrate snack before and during the
badminton match
C. Drink plenty of Xuids before, during, and after bed
time
D. Take insulin just before starting the badminton
match

31. A client is rushed to the emergency room due to

serious vehicle accident. The nurse is suspecting of
head injury. Which of the following assessment Yndings
would the nurse report to the physician?

A. CVP of 5mmHa
B. Glasgow Coma Scale score of 13
C. Polyuria and dilute urinary output
D. Insomnia

32. Mrs. Moore, 62-year-old, with diabetes is in the

emergency department. She stepped on a sharp sea
shells while walking barefoot along the beach. Mrs.
Moore did not notice that the object pierced the skin
until later that evening. What problem does the client
most probably have?

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 most probably have?

A. Nephropathy
B. Macroangiopathy
C. Carpal tunnel syndrome
D. Peripheral neuropathy

33. A client with gangrenous foot has undergone a

below-knee amputation. The nurse in the nursing care
unit knows that the priority nursing intervention in the
immediate post operative care of this client is:

A. Elevate the stump on a pillow for the Yrst 24 hours

B. Encourage use of trapeze
C. Position the client prone periodically
D. Apply a cone-shaped dressing

34. A client with a diagnosis of gastric ulcer is

complaining of syncope and vertigo. What would be the
initial nursing intervention by the nurse?

A. Monitor the client’s vital signs

B. Keep the client on bed rest
C. Keep the patient on bed rest
D. Give a stat dose of Sucralfate (Carafate)

35. After a right lower lobectomy on a 55-year-old client,

which action should the nurse initiate when the client is
transferred from the post anesthesia care unit?

A. Notify the family to report the client’s condition

B. Immediately administer the narcotic as ordered
C. Keep client on right side supported by pillows
D. Encourage coughing and deep breathing every 2
hours

36. The nurse is providing a discharge instruction about

the prevention of urinary stasis to a client with frequent

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 the prevention of urinary stasis to a client with frequent
bladder infection. Which of the following will the nurse
include in the instruction?

A. Drink 3-4 quarts of Xuid every day

B. Empty the bladder every 2-4 hours while awake
C. Encourage the use of coffee, tea, and colas for their
diuretic effect
D. Teach Kegel exercises to control bladder Xow

37. A male client visits the clinic for check-up. The client
tells the nurse that there is a yellow discharge from his
penis. He also experiences a burning sensation when
urinating. The nurse is suspecting of gonorrhea. What
teaching is necessary for this client?

A. Sex partner of 3 months ago must be treated

B. Women with gonorrhea are symptomatic
C. Use a condom for sexual activity
D. Sex partner needs to be evaluated

38. A client with AIDS is admitted in the hospital. He is

receiving intravenous therapy. While the nurse is
assessing the IV site, the client becomes confused and
restless and the intravenous catheter becomes
disconnected and minimal amount of the client’s blood
spills onto the Xoor. Which action will the nurse take to
remove the blood spill?

A. Promptly clean with a 1:10 solution of household

bleach and water
B. Promptly clean up the blood spill with full-strength
antimicrobial cleaning solution
C. Immediately mop the Xoor with boiling water
D. Allow the blood to dry before cleaning to decrease
the possibility of cross-contamination

39. Before surgery, the physician ordered pentobarbital

sodium (Nembutal) for the client to sleep. The night

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 sodium (Nembutal) for the client to sleep. The night
before the scheduled surgery, the nurse gave the pre-
medication. One hour later the client is still unable to
sleep. The nurse review the client’s chart and note the
physician’s prescription with an order to repeat. What
should the nurse do next?

A. Rub the client’s back until relaxed

B. Prepare a glass of warm milk
C. Give the second dose of pentobarbital sodium
D. Explore the client’s feelings about surgery

40. The nurse on the night shift is making rounds in the

nursing care unit. The nurse is about to enter to the
client’s room when a ventilator alarm sounds, what is the
Yrst action the nurse should do?

A. Assess the lung sounds

B. Suction the client right away
C. Look at the client
D. Turn and position the client

41. What effective precautions should the nurse use to

control the transmission of methicillin-resistant
Staphylococcus aureus (MRSA)?

A. Use gloves and handwashing before and after client

contact
B. Do nasal cultures on healthcare providers
C. Place the client on total isolation
D. Use mask and gown during care of the MRSA client

42. The postoperative gastrectomy client is scheduled

for discharge. The client asks the nurse, “When I will be
allowed to eat three meals a day like the rest of my
family?”. The appropriate nursing response is:

A. “You will probably have to eat six meals a day for

the rest of your life.”

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 the rest of your life.”
B. “Eating six meals a day can be a bother, can’t it?”
C. “Some clients can tolerate three meals a day by the
time they leave the hospital. Maybe it will be a little
longer for you.”
D. “ It varies from client to client, but generally in 6-12
months most clients can return to their previous
meal patterns”

43. A male client with cirrhosis is complaining of belly

pain, itchiness and his breasts are getting larger and
also the abdomen. The client is so upset because of the
discomfort and asks the nurse why his breast and
abdomen are getting larger. Which of the following is the
appropriate nursing response?

A. “How much of a difference have you noticed”

B. “It’s part of the swelling your body is experiencing”
C. “It’s probably because you have been less physically
active”
D. “Your liver is not destroying estrogen hormones that
all men produce”

44. A client is diagnosed with detached retina and

scheduled for surgery. Preoperative teaching of the
nurse to the client includes:

A. No eye pain is expected postoperatively

B. Semi-fowler’s position will be used to reduce
pressure in the eye.
C. Eye patches may be used postoperatively
D. Return of normal vision is expected following
surgery

45. A 70-year-old client is brought to the emergency

department with a caregiver. The client has
manifestations of anorexia, wasting of muscles and
multiple bruises. What nursing interventions would the
nurse implement?

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 nurse implement?

A. Talk to the client about the caregiver and support

system
B. Complete a gastrointestinal and neurological
assessment
C. Check the lab data for serum albumin, hematocrit
and hemoglobin
D. Complete a police report on elder abuse

46. A nurse is providing a discharge instruction to the

client about the self-catheterization at home. Which of
the following instructions would the nurse include?

A. Wash the catheter with soap and water after each

use
B. Lubricate the catheter with Vaseline
C. Perform the Valsalva maneuver to promote
insertion
D. Replace the catheter with a new one every 24 hour

47. The nurse in the nursing care unit is assigned to care

to a client who is Immunocompromised. The client tells
the nurse that his chest is painful and the blisters are
itchy. What would be the nursing intervention to this
client?

A. Call the physician

B. Give a prn pain medication
C. Clarify if the client is on a new medication
D. Use gown and gloves while assessing the lesions

48. A client is admitted and has been diagnosed with

bacterial (meningococcal) meningitis. The infection
control registered nurse visits the staff nurse caring to
the client. What statement made by the nurse reXects an
understanding of the management of this client?
A. speech pattern may be altered
B. Respiratory isolation is necessary for 24 hours after

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 B. Respiratory isolation is necessary for 24 hours after
antibiotics are started
C. Perform skin culture on the macular popular rash
D. Expect abnormal general muscle contractions

49. A 18-year-old male client had sustained a head injury

from a motorbike accident. It is uncertain whether the
client may have minimal but permanent disability. The
family is concerned regarding the client’s dijculty
accepting the possibility of long term effects. Which
nursing diagnosis is best for this situation?

A. Nutrition, less than body requirements

B. Injury, potential for sensory-perceptual alterations
C. Impaired mobility, related to muscle weakness
D. Anticipatory grieving, due to the loss of
independence

50. A client with AIDS is scheduled for discharge. The

client tells the nurse that one of his hobbies at home is
gardening. What will be the discharge instruction of the
nurse to the client knowing that the client is prone to
toxoplasmosis?

A. Wash all vegetables before cooking

B. Wear gloves when gardening
C. Wear a mask when travelling to foreign countries
D. Avoid contact with cats and birds

Answers and Rationales

1. D. The Heimlich Xutter valve has a one-way valve

that allows air and Xuid to drain. Underwater seal
drainage is not necessary. This can be connected to
a drainage bag for the patient’s mobility. The
absence of a long drainage tubing and the presence
of a one-way valve promote effective therapy
2. C. C = the normal CVP is 0-8 mmHg. This value
reXects hypervolemia. The right ventricular function

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 reXects hypervolemia. The right ventricular function
of this client reXects Xuid volume overload, and the
physician should be notiYed.
3. C. A hot tub bath or shower in the morning helps
many patients limber up and reduces the symptoms
of early morning stiffness. Cold and ice packs are
used to a lesser degree, though some clients state
that cold decreases localized pain, particularly
during acute attacks.
4. D. These substances stimulate the production of
hydrochloric acid, which is detrimental in peptic
ulcer disease.
5. D. The three-point gait is appropriate when weight
bearing is not allowed on the affected limb. The
swing-to and swing-through crutch gaits may also
be used when only one leg can be used for weight
bearing
s. A. The client needs to be told before surgery that
the catheter causes the urge to void. Attempts to
void around the catheter cause the bladder muscles
to contract and result in painful spasms.
7. B. Bland feedings should be given in small amounts
on a frequent basis to neutralize the hydrochloric
acid and to prevent overload
t. C. Chilling the tube before insertion assists in
relieving some of the nasal discomfort. Water-
soluble lubricants along with viscous lidocaine
(Xylocaine) may also be used. It is usually only
lightly lubricated before insertion
9. B. Whole milk should be avoided to include in the
client’s diet because it has 120 mg of sodium in 8 0z
of milk.
10. A. Alcohol is extremely drying and contributes to
skin break down. An emollient lotion should be
used.
11. D. Potassium inXuences the excitability of nerves
and muscles. When potassium is low and the client
is on digoxin, the risk of digoxin toxicity is
increased.

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 increased.
12. C. This position allows maximum expansion,
ventilation, and perfusion of the remaining lung.
13. A. These foods are high in potassium
14. B. Stress on the suture line should be avoided.
Prevent Xexion or hyperextension of the neck, and
provide a small pillow under thehead and neck.
Neck muscles have been affected during a
thyroidectomy, support essential for comfort and
incisional support.
15. A. A positive nitrogen balance is important for
meeting metabolic needs, tissue repair, and
resistance to infection. Caloric goals may be as high
as 5000 calories per day.
1s. C. The best early intervention would be to increase
Xuid intake, because constipation is common when
activity is decreased or usual routines have been
interrupted.
17. A. Because the client’s ability is to react to stress is
decreased, maintaining a quiet environment
becomes A nursing priority. Dehydration is a
common problem in Addison’s disease, so close
observation of the client’s hydration level is crucial.
To promote optimal hydration and sodium intake,
Xuid intake is increased, particularly Xuid containing
electrolytes, such as broths, carbonated beverages,
and juices.
1t. C. At about 48-72 hours, the client must be turned
onto the abdomen to prevent Xexion contractures.
19. B. The client should not drive for 2 weeks after
surgery to avoid stress on the incision. This reXects
a need for additional teaching.
20. A. Extremes in heat and cold will exacerbate
symptoms. Heat delays transmission of impulses
and increases fatigue.
21. A. Vigilant implementation of standard precautions
and medical asepsis is an effective means of
preventing infection
22. C. Noncompliance is a major problem in the

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 22. C. Noncompliance is a major problem in the
management of chronic disease. In hypertension,
the client often does not feel ill and thus does not
see a need to follow a treatment regimen.
23. B. An accumulation of blood from the kidney into
the abdomen would manifest itself with these
symptoms
24. D. Fluids liquefy secretions and therefore make it
easier to expectorate
25. D. Physical assessment guidelines recommend
listening for atleast 2 minutes in each quadrant (and
up to 5 minutes, not at least 5 minutes).
2s. A. Compression stockings promote venous return
and prevent peripheral pooling.
27. A. Placing food in the unaffected side of the mouth
assists in the swallowing process because the
client has sensation on that side and will have more
control over the swallowing process.
2t. D. Daily weights are taken following nephrectomy.
Daily increases of 2 lb or more are indicative of Xuid
retention and should be reported to the physician.
Intake and output records may also reXect this
imbalance.
29. A. Clients with cirrhosis have already coagulation
due to thrombocytopenia and vitamin K deYciency.
This could be a sign of bleeding
30. B. Exercise enhances glucose uptake, and the client
is at risk for an insulin reaction. Snacks with
carbohydrates will help.
31. C. These are symptoms of diabetes insipidus. The
patient can become hypovolemic and vasopressin
may reverse the Polyuria.
32. D. Peripheral neuropathy refers to nerve damage of
the hands and feet. The client did not notice that the
object pierced the skin.
33. A. The elevation of the stump on a pillow for the
Yrst 24 hours decreases edema and increases
venous return.
34. B. The priority is to maintain client’s safety. With

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 34. B. The priority is to maintain client’s safety. With
syncope and vertigo, the client is at high risk for
falling.
35. D. Coughing and deep breathing are essential for re-
expansion of the lung
3s. B. Avoiding stasis of urine by emptying the bladder
every 2-4 hours will prevent overdistention of the
bladder and future urinary tract infections.
37. D. If infected, the sex partner must be evaluated and
treated
3t. A. A 1:10 solution of household bleach and water is
recommended by the Centers for Disease Control
and Prevention to kill the human immunodeYciency
virus (HIV).
39. D. Given the data, presurgical anxiety is suspected.
The client needs an opportunity to talk about
concerns related to surgery before further actions
(which may mask the anxiety).
40. C. A quick look at the client can help identify the
type and cause of the ventilator alarm.
Disconnection of the tube from the ventilator,
bronchospasm, and anxiety are some of the obvious
reasons that could trigger an alarm.
41. A. Contact isolation has been advised by the
Centers for Disease Control and Prevention (CDC) to
control transmission of MRSA, which includes
gloves and handwashing.
42. D. In response to the question of the client, the
nurse needs to provide brief, accurate information.
Some clients who have had gastrectomies are able
to tolerate three meals a day before discharge from
the hospital. However, for the majority of clients, it
takes 6-12 months before their surgically reduced
stomach has stretched enough to accommodate a
larger meal.
43. A. This allows the client to elaborate his concern
and provides the nurse a baseline of assessment
44. C. Use of eye patches may be continued
postoperatively, depending on surgeon preference.

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 postoperatively, depending on surgeon preference.
This is done to achieve >90% success rate of the
surgery.
45. B. Assessment and more data collection are
needed. The client may have gastrointestinal or
neurological problems that account for the
symptoms. The anorexia could result from
medications, poor dentition, or indigestion, the
bruises may be attributed to ataxia, frequent falls,
vertigo, or medication.
4s. A. The catheter should be washed with soap and
water after withdrawal and placed in a clean
container. It can be reused until it is too hard or too
soft for insertion. Self-care, prevention of
complications, and cost-effectiveness are important
in home management.
47. D. The client may have herpes zoster (shingles), a
viral infection. The nurse should use standard
precautions in assessing the lesions.
Immunocompromised clients are at risk for
infection.
4t. B. After a minimum of 24 hours of IV antibiotics, the
client is no longer considered communicable.
Evaluation of the nurse’s knowledge is needed for
safe care and continuity of care.
49. D. Stem of the question supports this choice by
stating that the client has dijculty accepting the
potential disability.
50. B. Toxoplasmosis is an opportunistic infection and
a parasite of birds and mammals. The oocysts
remain infectious in moist soil for about 1 year.

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