Nurse Test (Foundation of Nursing) Answers and Rationale

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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.