Fundamentals of Nursing #2 | This is the second set of practice questions for fundamentals of nursing covering topics like vital signs, nursing process, critical thinking skills, and communication.
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Question 1 |
Which intervention is an example of primary prevention?
A | A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
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B | B. Administering measles, mumps, and rubella immunization to an infant.
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C | C. Obtaining a Papanicolaou smear to screen for cervical cancer.
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D | D. Using occupational therapy to help a patient cope with arthritis. |
Question 1 Explanation:
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.
Question 2 |
The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
A | A. Auscultation
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B | B. Inspection
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C | C. Percussion
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D | D. Palpation |
Question 2 Explanation:
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.
Question 3 |
Which statement regarding heart sounds is correct?
A | A. S1 and S2 sound equally loud over the entire cardiac area.
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B | B. S1 and S2 sound fainter at the apex.
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C | C. S1 and S2 sound fainter at the base.
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D | D. S1 is loudest at the apex, and S2 is loudest at the base. |
Question 3 Explanation:
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.
Question 4 |
The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A | A. Assessment
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B | B. Nursing diagnosis
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C | C. Planning
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D | D. Evaluation |
Question 4 Explanation:
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.
Question 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 | A. Fresh, green vegetables
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B | B. Bananas and oranges
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C | C. Lean red meat
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D | D. Creamed corn |
Question 5 Explanation:
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.
Question 6 |
The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
A | A. Lethal arrhythmias
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B | B. Malignant hypertension
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C | C. Status epilepticus
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D | D. Bone marrow suppression |
Question 6 Explanation:
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.
Question 7 |
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
A | A. Impaired gas exchanges related to increased blood flow.
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B | B. Fluid volume excess related to peripheral vascular disease.
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C | C. Risk for injury related to edema.
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D | D. Altered peripheral tissue perfusion related to venous congestion. |
Question 7 Explanation:
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.
Question 8 |
When positioned properly, the tip of a central venous catheter should lie in the:
A | A. Superior vena cava
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B | B. Basilica vein
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C | C. Jugular vein
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D | D. Subclavian vein |
Question 8 Explanation:
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.
Question 9 |
Nurse Rachmawati is revising a client’s care plan. During which step of the nursing process does such revision take place?
A | A. Assessment
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B | B. Planning
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C | C. Implementation
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D | D. Evaluation |
Question 9 Explanation:
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.
Question 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 | A. “The contraction phase of wound healing can take 2 to 3 years.”
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B | B. “Wound healing is very individual but within 4 months the scar should fade.
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C | C. “With your history and the type of location of the injury, it’s hard to say.”
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D | D. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.” |
Question 10 Explanation:
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.
Question 11 |
One aspect of implementation related to drug therapy is:
A | A. Developing a content outline.
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B | B. Documenting drugs given.
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C | C. Establishing outcome criteria.
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D | D. Setting realistic client goals. |
Question 11 Explanation:
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.
Question 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. A history of increased aspirin use.
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B | B. Recent pelvic surgery.
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C | C. An active daily walking program.
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D | D. A history of diabetes. |
Question 12 Explanation:
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.
Question 13 |
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
A | A. Administer sleeping medication before bedtime.
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B | B. Ask the client each morning to describe the quantity of sleep during the previous night.
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C | C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation.
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D | D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks. |
Question 13 Explanation:
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.
Question 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 | A. Dry sterile dressing
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B | B. Sterile petroleum gauze
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C | C. Moist, sterile saline gauze
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D | D. Povidone-iodine-soaked gauze |
Question 14 Explanation:
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.
Question 15 |
A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and the 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 | A. Unbundling
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B | B. Overbilling
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C | C. Upcoding
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D | D. Misrepresentation |
Question 15 Explanation:
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.
Question 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 | A. Encourage the client to ask questions about personal sexuality.
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B | B. Provide time for privacy.
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C | C. Provide support for the spouse or significant other.
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D | D. Suggest referral to a sex counselor or other appropriate professional. |
Question 16 Explanation:
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.
Question 17 |
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
A | A. Security
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B | B. Elimination
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C | C. Safety
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D | D. Belonging |
Question 17 Explanation:
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.
Question 18 |
A male client 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 | A. Inadequate vitamin D intake.
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B | B. Inadequate protein intake.
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C | C. Inadequate massaging of the affected area.
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D | D. Low calcium level. |
Question 18 Explanation:
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.
Question 19 |
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A | A. Acute pain related to surgery.
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B | B. Deficient fluid volume related to blood and fluid loss from surgery.
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C | C. Impaired physical mobility related to surgery.
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D | D. Risk for aspiration related to anesthesia. |
Question 19 Explanation:
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.
Question 20 |
The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
A | A. Extravasation
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B | B. Osteomalacia
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C | C. Petechiae
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D | D. Uremia |
Question 20 Explanation:
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.
Question 21 |
Which document addresses the client’s right to information, informed consent, and treatment refusal?
A | A. Standard of Nursing Practice
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B | B. Patient’s Bill of Rights
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C | C. Nurse Practice Act
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D | D. Code for Nurses |
Question 21 Explanation:
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.
Question 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 | A. Fail to show changes in blood pressure.
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B | B. Produce a false-high measurement.
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C | C. Cause sciatic nerve damage.
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D | D. Produce a false-low measurement. |
Question 22 Explanation:
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.
Question 23 |
Nurse Halimah 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 | A. Baked beans, hamburger, and milk
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B | B. Spaghetti with cream sauce, broccoli, and tea
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C | C. Bouillon, spinach, and soda
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D | D. Chicken cutlet, spinach, and soda |
Question 23 Explanation:
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.
Question 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 | A. Assess the client’s airway.
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B | B. Provide pain relief.
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C | C. Encourage deep breathing and coughing.
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D | D. Splint the chest wall with a pillow. |
Question 24 Explanation:
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.
Question 25 |
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and unproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
A | A. Unhappiness about the charge in leadership.
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B | B. Unexpected feelings and emotions among the staff.
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C | C. Fatigue from overwork and understaffing.
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D | D. Failure to incorporate staff in decision making. |
Question 25 Explanation:
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.
Question 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 | A. Promote fluid balance
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B | B. Prevent infection
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C | C. Promote rest
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D | D. Prevent injury |
Question 26 Explanation:
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.
Question 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 | A. Semi-Fowler’s
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B | B. Supine
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C | C. High-Fowler’s
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D | D. Side-lying |
Question 27 Explanation:
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.
Question 28 |
The nurse 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 | A. Anisocoria
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B | B. Ataxia
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C | C. Cataract
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D | D. Diplopia |
Question 28 Explanation:
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.
Question 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 | A. He may have a low threshold for pain.
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B | B. He was faking pain.
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C | C. Someone else gave him medication.
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D | D. The pain went away. |
Question 29 Explanation:
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.
Question 30 |
A female client is admitted to the emergency department with complaints of chest pain and 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. A neck tumor
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B | B. An electrolyte imbalance
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C | C. Dehydration
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D | D. Fluid overload |
Question 30 Explanation:
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.
Question 31 |
Critical thinking and the nursing process have which of the following in common? Both:
A | A. Are important to use in nursing practice.
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B | B. Use an ordered series of steps.
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C | C. Are patient-specific processes.
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D | D. Were developed specifically for nursing. |
Question 31 Explanation:
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.
Question 32 |
In which step of the nursing process does the nurse analyze data and identify client problems?
A | A. Assessment
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B | B. Diagnosis
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C | C. Planning outcomes
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D | D. Evaluation |
Question 32 Explanation:
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.
Question 33 |
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client’s health problem?
A | A. Assessment
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B | B. Diagnosis
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C | C. Planning outcomes
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D | D. Evaluation |
Question 33 Explanation:
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.
Question 34 |
What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to:
A | A. Identify personal biases that may affect his thinking and actions.
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B | B. Identify the most effective interventions for a patient.
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C | C. Communicate more efficiently with colleagues, patients, and families.
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D | D. Learn and remember new procedures and techniques. |
Question 34 Explanation:
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.
Question 35 |
The most important nursing intervention to correct skin dryness is:
A | A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection. |
B |
B
B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear.
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C | C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. |
D |
D
D. Avoid bathing the patient until the condition is remedied, and notify the physician.
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Question 35 Explanation:
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.
Question 36 |
How are critical thinking skills and critical thinking attitudes similar? Both are:
A | A. Influences on the nurse's problem solving and decision making.
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B | B. Like feelings rather than cognitive activities.
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C | C. Cognitive activities rather than feelings.
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D | D. Applicable in all aspects of a person's life. |
Question 36 Explanation:
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.
Question 37 |
The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, “I know I tend to feel negative about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let it be judgmental of this patient.” This best illustrates:
A | A. Theoretical knowledge
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B | B. Self-knowledge
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C | C. Using reliable resources
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D | D. Use of the nursing process |
Question 37 Explanation:
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.
Question 38 |
Which organization’s standards require that all patients be assessed specifically for pain?
A | A. American Nurses Association (ANA)
|
B | B. State nurse practice acts
|
C | C. National Council of State Boards of Nursing (NCSBN)
|
D | D. The Joint Commission |
Question 38 Explanation:
Correct Answer: D. (The Joint Commission).
The Joint Commission has developed assessment standards, including that all clients be assessed for pain.
Question 39 |
Which of the following is an example of data that should be validated?
A | A. The urinalysis report indicates there are white blood cells in the urine.
|
B | B. The client states she feels feverish; you measure the oral temperature at 98°F.
|
C | C. The client has clear breath sounds; you count a respiratory rate of 18.
|
D | D. The chest x-ray report indicates the client has pneumonia in the right lower lobe. |
Question 39 Explanation:
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.
Question 40 |
Which of the following is an example of appropriate behavior when conducting a client interview?
A | A. Recording all the information on the agency-approved form during the interview.
|
B | B. Asking the client, "Why did you think it was necessary to seek health care at this time?"
|
C | C. Using precise medical terminology when asking the client questions. |
D | D. Sitting, facing the client in a chair at the client's bedside, using active listening. |
Question 40 Explanation:
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.
Question 41 |
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply.
A | A. A body systems model
|
B | B. A head-to-toe framework
|
C | C. Maslow's hierarchy of needs
|
D | D. Gordon's functional health patterns
|
E | E. Adaptation Model of Nursing |
Question 41 Explanation:
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.
Question 42 |
The nurse is recording assessment data. She writes, “The patient seems worried about his surgery. Other than that, he had a good night.” Which errors did the nurse make? Select all that apply.
A | A. Used a vague generality.
|
B | B. Did not use the patient's exact words.
|
C | C. Used a "waffle" word (e.g., appears).
|
D | D. Recorded an inference rather than a cue.
|
E | E. Did not record the patient’s vital signs. |
Question 42 Explanation:
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.
Question 43 |
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
A | A. Ongoing assessment
|
B | B. Comprehensive physical assessment
|
C | C. Focused physical assessment
|
D | D. Psychosocial assessment |
Question 43 Explanation:
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.
Question 44 |
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment?
A | A. Sitting upright.
|
B | B. Lying flat on the back with knees flexed.
|
C | C. Lying flat on the back with arms and legs fully extended.
|
D | D. Side-lying with the knees flexed. |
Question 44 Explanation:
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.
Question 45 |
A terminally ill patient usually experiences all of the following feelings during the anger stage except:
A | A. Rage |
B | B. Envy
|
C | C. Numbness |
D | D. Resentment
|
Question 45 Explanation:
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.
Question 46 |
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient’s rectal area?
A | A. Sims'
|
B | B. Supine
|
C | C. Dorsal recumbent
|
D | D. Semi-Fowler's |
Question 46 Explanation:
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.
Question 47 |
How should the nurse modify the examination for a 7-year-old child?
A | A. Ask the parents to leave the room before the examination.
|
B | B. Demonstrate equipment before using it.
|
C | C. Allow the child to help with the examination.
|
D | D. Perform invasive procedures (e.g., otoscopic) last. |
Question 47 Explanation:
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.
Question 48 |
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination?
A | A. Dorsal recumbent
|
B | B. Semi-Fowler's
|
C | C. Lithotomy
|
D | D. Sims' |
Question 48 Explanation:
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.
Question 49 |
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
A | A. Heart murmurs
|
B | B. Jugular venous hums
|
C | C. Bowel sounds
|
D | D. Carotid bruits |
Question 49 Explanation:
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.
Question 50 |
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician’s office for a college physical. This patient is considered:
A | A. Obese
|
B | B. Overweight
|
C | C. Average
|
D | D. Underweight |
Question 50 Explanation:
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.
Question 51 |
Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?
A | A. Providing a back massage.
|
B | B. Feeding a client.
|
C | C. Providing hair care.
|
D | D. Providing oral hygiene. |
Question 51 Explanation:
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.
Question 52 |
The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?
A | A. Oral
|
B | B. Axillary
|
C | C. Radial
|
D | D. Heat sensitive tape |
Question 52 Explanation:
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.
Question 53 |
A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document these findings as:
A | A. Tachypnea
|
B | B. Hyperpyrexia
|
C | C. Arrhythmia
|
D | D. Tachycardia |
Question 53 Explanation:
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.
Question 54 |
Which of the following actions should the nurse take to use wide base support when assisting a client to get up in a chair?
A | A. Bend at the waist and place arms under the client’s arms and lift.
|
B | B. Face the client, bend knees, and place hands-on client’s forearm and lift.
|
C | C. Spread his or her feet apart.
|
D | D. Tighten his or her pelvic muscles. |
Question 54 Explanation:
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.
Question 55 |
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?
A | A. Oral
|
B | B. Axillary
|
C | C. Arterial line
|
D | D. Rectal |
Question 55 Explanation:
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.
Question 56 |
A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is:
A | A. Fowler’s position
|
B | B. Side-lying
|
C | C. Supine
|
D | D. Trendelenburg |
Question 56 Explanation:
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.
Question 57 |
A client is hospitalized for the first time, which of the following actions ensure the safety of the client?
A | A. Keep unnecessary furniture out of the way.
|
B | B. Keep the lights on at all times.
|
C | C. Keep side rails up at all times.
|
D | D. Keep all equipment out of view. |
Question 57 Explanation:
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.
Question 58 |
A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of the nursing process is being implemented here by the nurse?
A | A. Assessment
|
B | B. Diagnosis
|
C | C. Planning
|
D | D. Implementation |
Question 58 Explanation:
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.
Question 59 |
It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group, and community
A | A. Assessment
|
B | B. Nursing Process
|
C | C. Diagnosis
|
D | D. Implementation |
Question 59 Explanation:
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.
Question 60 |
Exchange of gases takes place in which of the following organs?
A | A. Kidney
|
B | B. Lungs
|
C | C. Liver
|
D | D. Heart |
Question 60 Explanation:
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.
Question 61 |
The chamber of the heart that receives oxygenated blood from the lungs is the:
A | A. Left atrium
|
B | B. Right atrium
|
C | C. Left ventricle
|
D | D. Right ventricle |
Question 61 Explanation:
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.
Question 62 |
A muscular enlarged pouch or sac that lies slightly to the left which is used for temporary storage of food…
A | A. Gallbladder
|
B | B. Urinary bladder
|
C | C. Stomach
|
D | D. Lungs
|
E | E. Rugae of the stomach |
Question 62 Explanation:
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.
Question 63 |
The ability of the body to defend itself against scientific invading agent such as bacteria, toxin, viruses, and foreign body:
A | A. Hormones
|
B | B. Secretion
|
C | C. Immunity
|
D | D. Glands |
Question 63 Explanation:
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.
Question 64 |
Hormones secreted by Islets of Langerhans
A | A. Progesterone
|
B | B. Testosterone
|
C | C. Insulin
|
D | D. Hemoglobin |
Question 64 Explanation:
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.
Question 65 |
It is a transparent membrane that focuses the light that enters the eyes to the retina.
A | A. Lens
|
B | B. Sclera
|
C | C. Cornea
|
D | D. Pupils |
Question 65 Explanation:
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.
Question 66 |
Which of the following is included in Orem’s theory?
A | A. Maintenance of a sufficient intake of air.
|
B | B. Self perception.
|
C | C. Love and belongingness.
|
D | D. Physiologic needs. |
Question 66 Explanation:
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.
Question 67 |
Which of the following cluster of data belong to Maslow’s hierarchy of needs
A | A. Love and belonging
|
B | B. Physiological needs
|
C | C. Self actualization
|
D | D. All of the above |
Question 67 Explanation:
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.
Question 68 |
This is characterized by severe symptoms relatively of short duration.
A | A. Chronic Illness
|
B | B. Acute Illness
|
C | C. Pain
|
D | D. Syndrome |
Question 68 Explanation:
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.
Question 69 |
Which of the following is the nurse’s role in health promotion?
A | A. Health risk appraisal
|
B | B. Teach client to be effective health consumer
|
C | C. Worksite wellness
|
D | D. None of the above |
Question 69 Explanation:
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.
Question 70 |
It is described as a collection of people who share some attributes of their lives.
A | A. Family
|
B | B. Illness
|
C | C. Community
|
D | D. Nursing |
Question 70 Explanation:
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.
Question 71 |
Five teaspoons is equivalent to how many milliliters (ml)?
A | A. 30 ml
|
B | B. 25 ml
|
C | C. 12 ml
|
D | D. 22 ml |
Question 71 Explanation:
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.
Question 72 |
1800 ml is equal to how many liters?
A | A. 1.8
|
B | B. 18000
|
C | C. 180
|
D | D. 2800 |
Question 72 Explanation:
Correct Answer: A. (1.8). 1,800 ml is equal to 1.8 liters.
Question 73 |
Which of the following is the abbreviation of drops?
A | A. Gtt.
|
B | B. Gtts.
|
C | C. Dp.
|
D | D. Dr. |
Question 73 Explanation:
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.
Question 74 |
The abbreviation for microdrop is…
A | A. µgtt
|
B | B. gtt
|
C | C. mdr
|
D | D. mgts |
Question 74 Explanation:
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.
Question 75 |
Which of the following is the meaning of PRN?
A | A. When advice
|
B | B. Immediately
|
C | C. When necessary
|
D | D. Now. |
Question 75 Explanation:
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.
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