Correct Answer: B. (Administering measles, mumps, and rubella immunization to an infant). Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future.

Correct Answer: B. (Inspection). Inspection always comes first when performing a physical examination. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

Correct Answer: D. (S1 is loudest at the apex, and S2 is loudest at the base). 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. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created.

Correct Answer: B. (Nursing diagnosis). The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community.

Correct Answer: B. (Bananas and oranges). 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. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.

Correct Answer: D. (Bone marrow suppression). The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used drug in the United States because of its known severe adverse effects, such as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.

Correct Answer: D. (Altered peripheral tissue perfusion related to venous congestion). 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. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke.

Correct Answer: A. (Superior vena cava). 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.

Correct Answer: D. (Evaluation). 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. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.

Correct Answer: C. (“With your history and the type of location of the injury, it’s hard to say.”) Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information. There is no doubt that diabetes plays a detrimental role in wound healing. It does so by affecting the wound healing process at multiple steps. Wound hypoxia, through a combination of impaired angiogenesis, inadequate tissue perfusion, and pressure-related ischemia, is a major driver of chronic diabetic wounds.

Correct Answer: B. (Documenting drugs given). 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.

Correct Answer: B. (Recent pelvic surgery). 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. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis.

Correct Answer: D. (Provide the client with normal sleep aids, such as pillows, back rubs, and snacks). The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep is a complex biological process. It is a reversible state of unconsciousness in which there are reduced metabolism and motor activity. Sleep disorders are a group of conditions that disturb the normal sleep patterns of a person. Sleep disorders are one of the most common clinical problems encountered. Inadequate or non-restorative sleep can interfere with normal physical, mental, social, and emotional functioning. Sleep disorders can affect overall health, safety, and quality of life.

Correct Answer: C. (Moist, sterile saline gauze). Moist, sterile saline dressings support would heal and are cost-effective. If the wound is infected and there are a lot of sloughs, which cannot be mechanically debrided, then a chemical debridement can be done with collagenase-based products. The goal is to help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture. When the wound bed is dry, use a dressing to increase moisture and if too wet and the surrounding skin is macerated, use material that will absorb excess fluid and protect the surrounding healthy skin.

Correct Answer: C. (Upcoding). Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. An upcoded bill can be sent to any payer—whether a private health insurer, Medicaid, Medicare, or the patient. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.

Correct Answer: D. (Suggest referral to a sex counselor or other appropriate professional). 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. 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.

Correct Answer: B. (Elimination). According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. Maslow’s hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization. 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.

Correct Answer: B. (Inadequate protein intake). A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Decubitus ulcers, also termed bedsores or pressure ulcers, are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body such as the ischium, greater trochanter, sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.

Correct Answer: D. (Risk for aspiration related to anesthesia). Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is believed to be an evolutionary reflex that developed as a method to prevent the aspiration of solid food particles. It is an essential component of evaluating the medullary brainstem and plays a role in the declaration of brain death.The other options, although important, are secondary.

Correct Answer: C. (Petechiae) Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown spots on the skin. They usually appear on the arms, legs, stomach, and buttocks. They can also be found inside the mouth or on the eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious. They can also appear as a reaction to certain medications.

Correct Answer: B. (Patient’s Bill of Rights). 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.

Correct Answer: B. (Produce a false-high measurement). 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.

Correct Answer: A. (Baked beans, hamburger, and milk). Baked beans, hamburger, and milk are all excellent sources of protein. Good choices include soy protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-fat dairy products. Avoid processed meats.

Correct Answer: A. (Assess the client’s airway). 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. Blunt trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-threatening. It is important to know the mechanism as management may be different. Most blunt trauma is managed non-operatively, whereas penetrating chest trauma often requires operative intervention. Pain management and splinting are important for the client’s comfort but would come after airway assessment.

Correct Answer: B. (Unexpected feelings and emotions among the staff). 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 feelings and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.

Correct Answer: B. (Prevent infection). The client is at risk for infection because WBC count is dangerously low. Neutrophils play an essential role in immune defenses because they ingest, kill, and digest invading microorganisms, including fungi and bacteria. Failure to carry out this role leads to immunodeficiency, which is mainly characterized by the presence of recurrent infections. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

Correct Answer: D. (Side-lying). 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.

Correct Answer: A. (Anisocoria). Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a common condition. The varied causes have implications ranging from life-threatening to completely benign, and a clinically guided history and examination is the first step in establishing a diagnosis.

Correct Answer: A. (He may have a low threshold for pain). 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. Italian females reported the highest sensitivity to both mechanical and electrical stimulation, while Swedes reported the lowest sensitivity. Mechanical pain thresholds differed more across cultures than did electrical pain thresholds. Cultural factors may influence response to type of pain test.

Correct Answer: D. (Fluid overload). 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. JVD is a sign of increased central venous pressure (CVP). That’s a measurement of the pressure inside the vena cava. CVP indicates how much blood is flowing back into the heart and how well the heart can move that blood into the lungs and the rest of the body.

Correct Answer: A. (Are important to use in nursing practice). Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. Neither is linear. Critical thinking applies to any discipline. n 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.

Correct Answer: B. (Diagnosis). In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.

Correct Answer: D. (Evaluation). During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

Correct Answer: A. (Identify personal biases that may affect his thinking and actions). The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affect all the other nursing actions, it is the most basic reason.

Correct Answer: C. (Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas). 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 non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing.

Correct Answer: A. (Influences on the nurse’s problem solving and decision making). Cognitive skills are used in complex thinking processes, such as problem-solving and decision making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity, intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex thinking processes. A few examples of these skills involve recognizing the need for more information, recognizing gaps in one’s own knowledge, and separating relevant information from irrelevant data. Critical thinking, which consists of intellectual skills and attitudes, can be used in all aspects of life.

Correct Answer: B. (Self-knowledge). Personal knowledge is self-understanding—awareness of one’s beliefs, values, biases, and so on. That best describes the nurse’s awareness that her bias can affect her patient care. Self-knowledge refers to knowledge of one’s own mental states, processes, and dispositions. Most agree it involves a capacity for understanding the representational properties of mental states and their role in shaping behavior.

Correct Answer: D. (The Joint Commission). The Joint Commission has developed assessment standards, including that all clients be assessed for pain.

Correct Answer: B. (The client states she feels feverish; you measure the oral temperature at 98°F). Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.

Correct Answer: D. (Sitting, facing the client in a chair at the client’s bedside, using active listening). Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the patient’s problems (active listening), empathy (communicating to the patient an accurate assessment of emotional state), and concern for the patient as a unique person are among the most important tools in the physician’s interpersonal repertoire. The difference between interviewing a patient who is lying flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient autonomy and active involvement in the interview.

Correct Answer: (C & D). Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and Maslow’s hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns are a nursing model.

Correct Answer: (A, C, D & E). The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Subjective and objective data collection are an integral part of this process.

Correct Answer: C. (Focused physical assessment). The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems.

Correct Answer: A. (Sitting upright). If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient’s physical condition restricts the comfort or ability of the patient to sit upright.

Correct Answer: C. (Numbness). Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient’s actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages.

Correct Answer: A. (Sims’) Sims’ position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler’s positions without causing harm to the joint.

Correct Answer: B. (Demonstrate equipment before using it). The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The physical examination is often the first direct contact between the nurse and the child. Establishing a trusting relationship between the child and the examiner is important. Throughout the examination the nurse should be sensitive to the cultural needs of and differences among children. Providing a quiet, private environment for the history and physical examination is important. The classic systematic approach to the physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner tailors the physical assessment to the child’s age and developmental level.

Correct Answer: B. (Semi-Fowler’s). If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. The Semi-Fowler’s position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle.

Correct Answer: C. (Bowel sounds). The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds.

Correct Answer: D. (Underweight). For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person’s weight in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening method for the weight category—underweight, healthy weight, overweight, and obesity.

Correct Answer: D. (Providing oral hygiene). Doing oral care requires the nurse to wear gloves. Standard precautions apply to the care of all patients, irrespective of their disease state. These precautions apply when there is a risk of potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous membranes. This includes the use of hand hygiene and personal protective equipment (PPE), with hand hygiene being the single most important means to prevent transmission of disease.

Correct Answer: B. (Axillary). Axilla is the most accessible body part in this situation. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.

Correct Answer: D. (Tachycardia). Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that’s too fast. How that’s defined may depend on age and physical condition. Generally speaking, for adults, a heart rate of more than 100 beats per minute (BPM) is considered too fast.

Correct Answer: B. (Face the client, bend knees, and place hands-on client’s forearm and lift). This is the proper way of supporting the client to get up in a chair that conforms to safety and proper body mechanics. It is important to use proper body mechanics as a health care professional for many reasons, foremost of which is to prevent injuries to both patient and provider. Health care professionals at the front line, especially those who deliver direct care to patients, are often in situations where they have to assist with moving patients from one position to another.

Correct Answer: B. (Axillary). Taking the temperature via the axilla is the most appropriate route. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.

Correct Answer: B. (Side-lying). An unconscious client is best placed on his side when doing oral care to prevent aspiration. An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing.

Correct Answer: C. (Keep side rails up at all time) Keeping the side rails up at all times ensures the safety of the client. The risk of falling increases with age and the number of times someone has been in hospital. During the client’s hospital stay, he may be more unsteady on his feet because of illness or surgery, or because he is unfamiliar with the hospital environment or is taking new medication.

Correct Answer: A. (Assessment). Assessment is the first phase of the nursing process where a nurse collects information about the client. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.

Correct Answer: B. (Nursing Process). The statement describes the Nursing Process. The Nursing Process is the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.

Correct Answer: B. (Lungs). Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli and a network of tiny blood vessels called capillaries, which are located in the walls of the alveoli.

Correct Answer: A. (Left atrium). The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. In the lungs, the blood oxygenates as it passes through the capillaries where it is close enough to the oxygen in the alveoli of the lungs. This oxygenated blood is collected by the four pulmonary veins, two from each lung. All four of these veins open into the left atrium that acts as a collection chamber for oxygenated blood. Just like the right atrium, the left atrium passes the blood onto its ventricle both by passive flow and active pumping.

Correct Answer: C. (Stomach). The stomach is a muscular organ located on the left side of the upper abdomen. It is a saclike expansion of the digestive tract of a vertebrate that is located between the esophagus and duodenum. The major part of the digestion of food occurs in the stomach.

Correct Answer: C. (Immunity). Immunity is the ability of an organism to resist a particular infection or toxin by the action of specific antibodies or sensitized white blood cells. The Immune response is the body’s ability to stay safe by affording protection against harmful agents and involves lines of defense against most microbes as well as specialized and highly specific responses to a particular offender. This immune response classifies as either innate which is non-specific and adaptive acquired which is highly specific.

Correct Answer: C. (Insulin). The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Insulin is a peptide hormone secreted in the body by beta cells of islets of Langerhans of the pancreas and regulates blood glucose levels. Medical treatment with insulin is indicated when there is inadequate production or increased demands of insulin in the body.

Correct Answer: A. (Lens). The lens is located in the eye. By changing its shape, the lens changes the focal distance of the eye. In other words, it focuses the light rays that pass through it (and onto the retina) in order to create clear images of objects that are positioned at various distances. It also works together with the cornea to refract, or bend, light. The lens consists of the lens capsule, the lens epithelium, and the lens fibers. The lens capsule is the smooth, transparent outermost layer of the lens, while the lens fibers are long, thin, transparent cells that form the bulk of the lens. The lens epithelium lies between these two and is responsible for the stable functioning of the lens. It also creates lens fibers for the lifelong growth of the lens.

Correct Answer: A. (Maintenance of a sufficient intake of air). Dorothea Orem’s Self-Care Theory defined Nursing as “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness.” The Self-Care or Self-Care Deficit Theory of Nursing is composed of three interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems, which is further classified into wholly compensatory, partial compensatory and supportive-educative. Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.

Correct Answer: D. (All of the above). All of the choices are part of Maslow’s Hierarchy of Needs. Maslow first introduced his concept of a hierarchy of needs in his 1943 paper “A Theory of Human Motivation” and his subsequent book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other, more advanced needs. As a humanist, Maslow believed that people have an inborn desire to be self-actualized, that is, to be all they can be. In order to achieve these ultimate goals, however, a number of more basic needs must be met such as the need for food, safety, love, and self-esteem.

Correct Answer: B. (Acute Illness). Acute illnesses are different than chronic illnesses in that they usually develop quickly and they only last a short time – usually a few days or weeks. Acute illnesses are often caused by viral or bacterial infections.

Correct Answer: B. (Teach client to be effective health consumer). Nurses play a huge role in illness prevention and health promotion. Nurses assume the role of ambassadors of wellness. The World Health Organization (WHO) defines health promotion as a process of enabling people to increase control over and to improve their health (WHO, 1986). Nurses are best qualified to take on the job of health promoter due to their expertise. There are few health care occupations that have the high level of health education knowledge, skills, theory, and research to be able to focus on prevention because it is considered part of their professional development focus.

Correct Answer: C. (Community). A community is defined by the shared attributes of the people in it, and/or by the strength of the connections among them. When an organization is identifying communities of interest, the shared attribute is the most useful definition of a community.

Correct Answer: B. (25 ml). One teaspoon is equal to 5ml. Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check.

Correct Answer: A. (1.8). 1,800 ml is equal to 1.8 liters.

Correct Answer: B. (Gtts). Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviations for measurement. Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients.

Correct Answer: A. (µgtt). The abbreviation for microdrop is µgtt. When abbreviations are used in documents given to the patient, the potential for misunderstanding can increase. Information needs to be clear and unambiguous to improve patients’ comprehension.

Correct Answer: C. (When necessary). PRN comes from the Latin “pro re nata” meaning, “for an occasion that has arisen or as circumstances require”. When an abbreviation is less known outside of the organization or clinical specialty, it is necessary to spell out the abbreviation throughout the discharge summary to prevent misunderstanding and confusion by the physician or health care organization that receives the summary.