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Fundamentals of Nursing Questions Part 2 Answers and Rationale

admin — Wed, 10 Mar 2010 07:18:26 +0000

Answer B. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.
Answer B. Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
Answer D. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
Answer B. The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
Answer D. The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
Answer D. Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.
Answer A. When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Answer D. During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
Answer C. Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
Answer B. Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
Answer B. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
Answer D. The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail.
Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
Answer C. Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
Answer D. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
Answer B. According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
Answer D. Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
Answer B. The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
Answer A. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
Answer B. The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
Answer A. People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
Answer D. Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.

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Fundamentals of Nursing Questions Part 2

admin — Mon, 08 Mar 2010 08:41:07 +0000

1.    Which intervention is an example of primary prevention?
a.    Administering digoxin (Lanoxicaps) to a patient with heart failure
b.    Administering a measles, mumps, and rubella immunization to an infant
c.    Obtaining a Papanicolaou smear to screen for cervical cancer
d.    Using occupational therapy to help a patient cope with arthritis

2.    The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
a.    Auscultation
b.    Inspection
c.    Percussion
d.    Palpation

3.    Which statement regarding heart sounds is correct?
a.    S1 and S2 sound equally loud over the entire cardiac area.
b.    S1 and S2 sound fainter at the apex
c.    S1 and S2 sound fainter at the base
d.    S1 is loudest at the apex, and S2 is loudest at the base

4.    The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
a.    Assessment
b.    Nursing diagnosis
c.    Planning
d.    Evaluation

5.    A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
a.    Fresh, green vegetables
b.    Bananas and oranges
c.    Lean red meat
d.    Creamed corn

6.    The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
a.    Lethal arrhythmias
b.    Malignant hypertension
c.    Status epilepticus
d.    Bone marrow suppression

7.    A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
a.    Impaired gas exchanges related to increased blood flow
b.    Fluid volume excess related to peripheral vascular disease
c.    Risk for injury related to edema
d.    Altered peripheral tissue perfusion related to venous congestion

8.    When positioned properly, the tip of a central venous catheter should lie in the:
a.    Superior vena cava
b.    Basilica vein
c.    Jugular vein
d.    Subclavian vein

9.    Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
a.    Assessment
b.    Planning
c.    Implementation
d.    Evaluation

10.    A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
a.    “The contraction phase of wound healing can take 2 to 3 years.”
b.    “Wound healing is very individual but within 4 months the scar should fade.”
c.    “With your history and the type of location of the injury, it’s hard to say.”
d.    “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”

11.    One aspect of implementation related to drug therapy is:
a.    Developing a content outline
b.    Documenting drugs given
c.    Establishing outcome criteria
d.    Setting realistic client goals

12.    A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
a.    A history of increased aspirin use
b.    Recent pelvic surgery
c.    An active daily walking program
d.    A history of diabetes

13.    Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
a.    Administer sleeping medication before bedtime
b.    Ask the client each morning to describe the quantity of sleep during the previous night
c.    Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
d.    Provide the client with normal sleep aids, such as pillows, back rubs, and snacks

14.    While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
a.    Dry sterile dressing
b.    Sterile petroleum gauze
c.    Moist, sterile saline gauze
d.    Povidone-iodine-soaked gauze

15.    A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
a.    Unbundling
b.    Overbilling
c.    Upcoding
d.    Misrepresentation

16.    A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
a.    Encourage the client to ask questions about personal sexuality
b.    Provide time for privacy
c.    Provide support for the spouse or significant other
d.    Suggest referral to a sex counselor or other appropriate professional

17.    Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
a.    Security
b.    Elimination
c.    Safety
d.    Belonging

18.    A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
a.    Inadequate vitamin D intake
b.    Inadequate protein intake
c.    Inadequate massaging of the affected area
d.    Low calcium level

19.    A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
a.    Acute pain related to surgery
b.    Deficient fluid volume related to blood and fluid loss from surgery
c.    Impaired physical mobility related to surgery
d.    Risk for aspiration related to anesthesia

20.    Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
a.    Extravasation
b.    Osteomalacia
c.    Petechiae
d.    Uremia

21.    Which document addresses the client’s right to information, informed consent, and treatment refusal?
a.    Standard of Nursing Practice
b.    Patient’s Bill of Rights
c.    Nurse Practice Act
d.    Code for Nurses

22.    If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
a.    Fail to show changes in blood pressure
b.    Produce a false-high measurement
c.    Cause sciatic nerve damage
d.    Produce a false-low measurement

23.    Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
a.    Baked beans, hamburger, and milk
b.    Spaghetti with cream sauce, broccoli, and tea
c.    Bouillon, spinach, and soda
d.    Chicken cutlet, spinach, and soda

24.    A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
a.    Assess the client’s airway
b.    Provide pain relief
c.    Encourage deep breathing and coughing
d.    Splint the chest wall with a pillow

25.    A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
a.    Unhappiness about the charge in leadership
b.    Unexpected feeling and emotions among the staff
c.    Fatigue from overwork and understaffing
d.    Failure to incorporate staff in decision making

26.    A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
a.    Promote fluid balance
b.    Prevent infection
c.    Promote rest
d.    Prevent injury

27.    Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
a.    Semi-Fowler’s
b.    Supine
c.    High-Fowler’s
d.    Side-lying

28.    Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
a.    Anisocoria
b.    Ataxia
c.    Cataract
d.    Diplopia

29.    The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
a.    He may have a low threshold for pain
b.    He was faking pain
c.    Someone else gave him medication
d.    The pain went away
30.    A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
a.    A neck tumor
b.    An electrolyte imbalance
c.    Dehydration
d.    Fluid overload

Answers and Rationale

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Fundamentals of Nursing Questions Part 1 Share this on Facebook Tweet This! Email this via...
Fundamentals of Nursing Questions Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Fundamentals of Nursing Questions Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...

Fundamentals of Nursing Questions Part 1 Answers and Rationale

admin — Fri, 05 Mar 2010 06:09:05 +0000

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Answer B. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.
Answer C. The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Answer C. Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
Answer C. A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
Answer A. Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Answer B. After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Answer D. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
Answer A. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Answer B. Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
Answer B. When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.
Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.
Answer C. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Answer C. The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
Answer C. The nurse solves the problem as follows:

10,000 units/7,500 units = 1 ml/X

10,000 X = 7,500

X= 7,500/10,000 or ¾ ml

Answer C. To convert Fahrenheit degrees to centigrade, use this formula:

C degrees = (F degrees – 32) x 5/9

C degrees = (102 – 32) 5/9

+ 70 x 5/9

38.9 degrees C

Answer D. All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
Answer C. In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
Answer D. The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.
Answer A. Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves.
Answer A. When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.
Answer C. The nurse should give ½ ml of the drug. The dosage is calculated as follows:

250 mg/X=500 mg/1 ml

500x=250

X=1/2 ml

Answer C. Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.
Answer A. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.
Answer C. The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.
Answer A. The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.
Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:

125/60 min = X/1 minute

60X = 125X = 2.1 ml/minute

To find the number of drops/minute:

2.1 ml/X gtts = 1 ml/15 gtts

X = 32 gtts/minute, or 32 drops/minute

Answer A. Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
Answer D. During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.

Fundamentals of Nursing Questions Part 1

admin — Wed, 03 Mar 2010 09:55:10 +0000

1.    Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
a.    Decreased plasma drug levels
b.    Sensory deficits
c.    Lack of family support
d.    History of Tourette syndrome

2.    When examining a patient with abdominal pain the nurse in charge should assess:
a.    Any quadrant first
b.    The symptomatic quadrant first
c.    The symptomatic quadrant last
d.    The symptomatic quadrant either second or third

3.    The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
a.    Vital signs
b.    Laboratory test result
c.    Patient’s description of pain
d.    Electrocardiographic (ECG) waveforms

4.    A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
a.    A palpable radial pulse
b.    A palpable ulnar pulse
c.    Cool, pale fingers
d.    Pink nail beds

5.    Which of the following planes divides the body longitudinally into anterior and posterior regions?
a.    Frontal plane
b.    Sagittal plane
c.    Midsagittal plane
d.    Transverse plane

6.    A female patient with a terminal illness is in denial. Indicators of denial include:
a.    Shock dismay
b.    Numbness
c.    Stoicism
d.    Preparatory grief

7.    The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
a.    Position the head of the bed flat
b.    Helps the patient dangle the legs
c.    Stands behind the patient
d.    Places the chair facing away from the bed

8.    A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
a.    Asking frequently if the patient understands the instruction
b.    Asking an interpreter to replay the instructions to the patient.
c.    Writing out the instructions and having a family member read them to the patient
d.    Demonstrating the procedure and having the patient return the demonstration

9.    Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
a.    Discard the syringe to avoid a medication error
b.    Obtain a label for the syringe from the pharmacy
c.    Use the syringe because it looks like it contains the same medication the nurse was prepared to give
d.    Call the day nurse to verify the contents of the syringe

10.    When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
a.    Faster drug clearance
b.    Aging-related physiological changes
c.    Increased amount of neurons
d.    Enhanced blood flow to the GI tract

11.    A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
a.    Manager
b.    Educator
c.    Caregiver
d.    Patient advocate

12.    A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
a.    “Everything will be fine. Don’t worry.”
b.    “Read this manual and then ask me any questions you may have.”
c.    “Why don’t you listen to the radio?”
d.    “Let’s talk about what’s bothering you.”

13.    A scrub nurse in the operating room has which responsibility?
a.    Positioning the patient
b.    Assisting with gowning and gloving
c.    Handling surgical instruments to the surgeon
d.    Applying surgical drapes

14.    A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
a.    Leave the medication at the patient’s bedside
b.    Tell the patient to be sure to take the medication. And then leave it at the bedside
c.    Return shortly to the patient’s room and remain there until the patient takes the medication
d.    Wait for the patient to return to bed, and then leave the medication at the bedside

15.    The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
a.    ¼ ml
b.    ½ ml
c.    ¾ ml
d.    1 ¼ ml

16.    The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
a.    39 degrees C
b.    47 degrees C
c.    38.9 degrees C
d.    40.1 degrees C

17.    To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
a.    Red blood cell count
b.    Sputum culture
c.    Total hemoglobin
d.    Arterial blood gas (ABG) analysis

18.    The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
a.    The bell detects high-pitched sounds best
b.    The diaphragm detects high-pitched sounds best
c.    The bell detects thrills best
d.    The diaphragm detects low-pitched sounds best

19.    A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
a.    Within 1 month
b.    Within 3 months
c.    Within 6 months
d.    Within 12 months

20.    Which human element considered by the nurse in charge during assessment can affect drug administration?
a.    The patient’s ability to recover
b.    The patient’s occupational hazards
c.    The patient’s socioeconomic status
d.    The patient’s cognitive abilities

21.    An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
a.    Primary prevention
b.    Secondary prevention
c.    Tertiary prevention
d.    Passive prevention

22.    What does the nurse in charge do when making a surgical bed?
a.    Leaves the bed in the high position when finished
b.    Places the pillow at the head of the bed
c.    Rolls the patient to the far side of the bed
d.    Tucks the top sheet and blanket under the bottom of the bed

23.    The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
a.    2 ml
b.    1 ml
c.    ½ ml
d.    ¼ ml

24.    Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
a.    Prolonged half-life
b.    Poor absorption
c.    Potential for drug dependence
d.    Potential for hepatotoxicity

25.    Which nursing action is essential when providing continuous enteral feeding?
a.    Elevating the head of the bed
b.    Positioning the patient on the left side
c.    Warming the formula before administering it
d.    Hanging a full day’s worth of formula at one time

26.    When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
a.    Top of the tongue
b.    Roof of the mouth
c.    Floor of the mouth
d.    Inside of the cheek

27.    Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
a.    Cleaning from the center outward in a circular motion
b.    Removing the drain before cleaning the skin
c.    Cleaning briskly around the site with alcohol
d.    Wearing sterile gloves and a mask

28.    The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
a.    15 drop per minute
b.    21 drop per minute
c.    32 drop per minute
d.    125 drops per minute

29.    A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
a.    Restlessness
b.    Pale, warm, dry skin
c.    Heart rate of 110 beats/minute
d.    Urine output of 30 ml/hour

30.    Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
a.    Radial
b.    Brachial
c.    Femoral
d.    Carotid

Answers and Rationale

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Nurse Test (Foundation of Nursing) Answers and Rationale

admin — Thu, 21 Jan 2010 02:28:00 +0000

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1. Answer – D. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use nonirritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. Bathing may be limited but need not be avoided entirely. The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary.

2. Answer – C. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. It improves circulation but does not result in vasoconstriction. The nurse can assess the patient’s condition throughout the bath, regardless of washing technique, and should feel no strain while bathing the patient.

3. Answer – B. Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming. Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep.

4. Answer – C. Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives.

5. Answer – A. Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep.

6. Answer – D. By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. The other choices are valid reasons for using restraints.

7. Answer – D. When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints.

8. Answer – C. Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance.

9. Answer – C. Numbness is typical of the depression stage, when the patient feels a great sense of loss. The anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?”

10. Answer – C. According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured.

11. Answer – C. Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles become weak and atonic, and periods of apnea occur during respiration.

12. Answer – B. The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. The National League of Nursing’s (NLN’s) major function is accrediting nursing education programs in the
United States. The American Medical Association (AMA) is a national organization of physicians. The American Nurses’ Association (ANA) is a national organization of registered nurses.

13. Answer – A. Before instituting isolation precaution, the nurse must first determine the organism’s mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a grown, and gloves when coming in direct contact with the patient. The organism’s Gram-straining characteristics reveal whether the organism is gram-negative or gram-positive, an important criterion in the physician’s choice for drug therapy and the nurse’s development of an effective plan of care. The nurse also needs to know whether the organism is susceptible to antibiotics, but this could take several days to determine; if she waits for the results before instituting isolation precautions, the organism could be transmitted in the meantime. The patient’s susceptibility to the organism has already been established. The nurse would not be instituting isolation precautions for a noninfected patient.

14. Answer – C. Placing the specimen in a sterile container ensures that it will not become contaminated. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth).

15. Answer – D. An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressured steam, is used because it can destroy all forms of microorganisms, including spores.

16. Answer – C. Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should than be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment.

17. Answer – C. Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in swelling and pallor, not erythema, near the insertion site. The patient has no evidence of bleeding.

18. Answer – B. Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication. Shaking the vial vigorously can break down the medication and alter its pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent.

19. Answer – C. When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol before injecting the insulin.

20. Answer – A. 25 gtt/minute

21. Answer – A. 0.5 ml

22. Answer – B. Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure accurate measurements.

23. Answer – C. After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. In this situation, the patient recently ingested medication, so the nurse needs to check for remnants of the medication to help determine whether the patient retained enough of it to be effective. The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an antiemetic.

24. Answer – B. A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine.

25. Answer – B. A new assistant nurse manger should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change. Written assignments allow all staff members to know their own and others responsibilities and serve as a checklist for the manager, enabling her to gauge whether the unit is being run effectively and whether patients are receiving appropriate care. Telling the staff nurses that she is making changes to benefit their performance should occur only after the nurse has made a thorough evaluation. Evaluations are usually done on a yearly basis or as needed.

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Nurse Test (Foundation of Nursing)

admin — Tue, 19 Jan 2010 06:18:00 +0000

1. The most important nursing intervention to correct skin dryness is:

a. Avoid bathing the patient until the condition is remedied, and notify the physician

b. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear

c. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection

d. Encourage the patient to increase his fluid intake, use nonirritating soap when bathing the patient, and apply lotion to the involved areas

2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:

a. Provides an opportunity for skin assessment

b. Avoids undue strain on the nurse

c. Increases venous blood return

d. Causes vasoconstriction and increases circulation

3. Vivid dreaming occurs in which stage of sleep?

a. Stage I non-REM

b. Rapid eye movement (REM) stage

c. Stage II non-REM

d. Delta stage

4. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:

a. Flurazepam

b. Temazepam

c. Tryptophan

d. Methotrimeprazine

5. Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:

a. Have the patient take a 30- to 60-minute nap in the afternoon

b. Turn on the television in the patient’s room

c. Provide quiet music and interesting reading material

d. Massage the patient’s back with long strokes

6. Restraints can be used for all of the following purposes except to:

a. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters

b. Prevent a patient from falling out of bed or a chair

c. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety

d. Prevent a patient from becoming confused or disoriented

7. Which of the following is the nurse’s legal responsibility when applying restraints?

a. Document the patient’s behavior

b. Document the type of restraint used

c. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others

d. All of the above

8. Kubler-Ross’s five successive stages of death and dying are:

a. Anger, bargaining, denial, depression, acceptance

b. Denial, anger, depression, bargaining, acceptance

c. Denial, anger, bargaining, depression acceptance

d. Bargaining, denial, anger, depression, acceptance

9. A terminally ill patient usually experiences all of the following feelings during the anger stage except:

a. Rage

b. Envy

c. Numbness

d. Resentment

10. Nurses and other health care provides often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

a. Taking psychology courses related to gerontology

b. Reading books and other literature on the subject of thanatology

c. Reflecting on the significance of death

d. Reviewing varying cultural beliefs and practices related to death

11. Which of the following symptoms is the best indicator of imminent death?

a. A weak, slow pulse

b. Increased muscle tone

c. Fixed, dilated pupils

d. Slow, shallow respirations

12. A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:

a. National League for Nursing (NLN)

b. Centers for Disease Control (CDC)

c. American Medical Association (AMA)

d. American Nurses Association (ANA)

13. To institute appropriate isolation precautions, the nurse must first know the:

a. Organism’s mode of transmission

b. Organism’s Gram-staining characteristics

c. Organism’s susceptibility to antibiotics

d. Patient’s susceptibility to the organism

14. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

a. Have the patient place the specimen in a container and enclose the container in a plastic bag

b. Have the patient expectorate the sputum while the nurse holds the container

c. Have the patient expectorate the sputum into a sterile container

d. Offer the patient an antiseptic mouthwash just before he expectorate the sputum

15. An autoclave is used to sterilize hospital supplies because:

a. More articles can be sterilized at a time

b. Steam causes less damage to the materials

c. A lower temperature can be obtained

d. Pressurized steam penetrates the supplies better

16. The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

a. Wash the gloves before removing them

b. Gently pull on the fingers of the gloves when removing them

c. Gently pull just below the cuff and invert the gloves when removing them

d. Remove the gloves and then turn them inside out

17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematons. This usually indicates:

a. Infection

b. Infiltration

c. Phlebitis

d. Bleeding

18. To ensure homogenization when diluting powdered medication in a vial, the nurse should:

a. Shake the vial vigorously

b. Roll the vial gently between the palms

c. Invert the vial and let it stand for 1 minute

d. Do nothing after adding the solution to the vial

19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:

a. Assess the injection site

b. Select the appropriate injection site

c. Check the syringe to verify that the nurse has removed the prescribed insulin dose

d. Clean the injection site in a circular manner with and alcohol sponge

20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?

a. 25 gtt/minute

b. 37 gtt/minute

c. 50 gtt/minute

d. 60 gtt/minute

21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

a. 0.5 ml

b. 0.75 ml

c. 1 ml

d. 2 ml

22. How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

a. Draw up the NPH insulin, then the regular insulin, in the same syringe

b. Draw up the regular insulin, then the NPH insulin, in the same syringe

c. Use two separate syringe

d. Check with the physician

23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

a. Call the physician

b. Remedicate the patient

c. Observe the emesis

d. Explain to the patient that she can do nothing to help him

24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:

a. Trauma has occurred

b. His 24-hour output is adequate

c. He has a urinary tract infection

d. Residual urine remains in the bladder after voiding

25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

a. Writing down all assignments

b. Making changes after evaluating the situation and having discussions with the staff.

c. Telling the staff nurses that she is making changes to benefit their performance

d. Evaluating the clinical performance of each staff nurse in a private conference

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