fundamentals of nursing (group 1)-- 92 question

FUNDAMENTALS OF NURSING

1. What best describes nurses as a care provider?

A. Determine client’s needB. Provide direct nursing careC. Help client recognize and cope with stressful psychological situationD. Works in combined effort with all those involved in patient’s care

Rationale: A. You can never provide nursing care if you don't know what are the needs of the client. How can you provide an effective postural drainage if you do not know where is the bulk of the client's secretion? Therefore, the best description of a care provider is the accurate and prompt determination of the client's need to be able to render an appropriate nursing care.

Reference: Fundamentals of Nursing, Kozier and Erb’s

Core competency: CORE COMPETENCY 1: Demonstrate knowledge based on health/illness status of individual/ groups

Nursing process: assessment

Cognitive domain: knowledge

2. Refers to the degree of resistance the potential host has against a certain pathogen

A. SusceptibilityB. ImmunityC. VirulenceD. Etiology

Rationale: a. Immunity is the ABSOLUTE Resistance to a pathogen considering that person has an INTACT IMMUNITY while susceptibility is the DEGREE of resistanca. Degree of resistance means how well the individual would combat the pathogens and repel infection or invasion of these disease causing organisms. A susceptible person is someone who has a very low degree of resistance to combat pathogens. An Immune person is someone that can easily repel specific pathogens. However, remember that even if a person is IMMUNE [Vaccination] Immunity can always be impaired in cases of chemotherapy, HIV, Burns, etc.





3. Diseases that result from changes in the normal structure, from recognizable anatomical changes in an organ or body tissue is termed as

A. FunctionalB. Occupational

C. InorganicD. Organic

Rationale: d. As the word implies, ORGANIC Diseases are those that causes a CHANGE in the structure of the organs and systems. Inorganic diseases is synonymous with FUNCTIONAL diseases wherein, There is no evident structural, anatomical or physical change in the structure of the organ or system but function is altered due to other causes, which is usually due to abnormal response of the organ to stressors. Therefore, ORGANIC BRAIN SYNDROME are anatomic and physiologic change in the BRAIN that is NON PROGRESSIVE BUT IRREVERSIBLE caused by alteration in structure of the brain and it's supporting structure which manifests different sign and symptoms of neurological, physiologic and psychologic alterations. Mental disorders manifesting symptoms of psychoses without any evident organic or structural damage are termed as INORGANIC PSYCHOSES while alteration in the organ structures that causes symptoms of bizarre psychotic behavior is termed as ORGANIC PSYCHOSES.





4. In what level of prevention according to Leavell and Clark does the nurse support the client in obtaining OPTIMAL HEALTH STATUS after a disease or injury?

A. PrimaryB. SecondaryC. TertiaryD. None of the above

Rationale: c. Perhaps one of the easiest concept but asked frequently in the NLA. Primary refers to preventions that aim in preventing the diseasa. Examples are healthy lifestyle, good nutrition, knowledge seeking behaviors etc. Secondary prevention deal with early diagnostics, case finding and treatments. Examples are monthly breast self exam, Chest X-RAY, Antibiotic treatment to cure infection, Iron therapy to treat anemia etc. Tertiary prevention aims on maintaining optimum level of functioning during or after the impact of a disease that threatens to alter the normal body functioninc. Examples are prosthetics fitting for an amputated leg after an accident, Self-monitoring of glucose among diabetics, TPA Therapy after stroke etc.




Cognitive domain: comprehension

5. Which is the best way to disseminate information to the public?

A. Newspaper

B. School bulletinsC. Community bill boardsD. Radio and Television

Rationale: d. The best way to disseminate information to the public is by TELEVISION followed by RADIO. This is how the DOH establishes it’s IEC Programs other than publishing posters, leaflets and brochures. An emerging new way to disseminate is through the internet.





6. Also known as STERILE TECHNIQUE

A. Surgical AsepsisB. Medical AsepsisC. SepsisD. Asepsis

Rationale: a. Surgical Asepsis is also known as STERILE TECHNIQUE while Medical Asepsis is synonymous with CLEAN TECHNIQUE.





7. This is a process of removing pathogens but not their spores.

A. SterilizationB. Auto clavingC. DisinfectionD. Medical asepsis

Rationale: c. Both A and B are capable of killing spores. Autoclaving is a form of Sterilization. Medical Asepsis is a PRACTICE designed to minimize or reduce the transfer of pathogens, also known as your CLEAN TECHNIQUA. Disinfection is the PROCESS of removing pathogens but not their spores.





8. This is considered as the most important aspect of hand washing

A. TimeB. FrictionC. WaterD. Soap

Rationale: b. The most important aspect of hand washing is FRICTION. The rest, will just enhance friction. The use of soap lowers the surface tension thereby increasing the effectiveness of friction. Water helps remove transient bacteria by working with soap to create the lather that reduces surface tension. Time is of essence but friction is the most essential aspect of hand washing.





9. The minimum time in washing each hand should never be below

A. 5 secondsB. 10 secondsC. 15 secondsD. 30 seconds

Rationale: b. According to Kozier, The minimum time required for watching each hands is 10 seconds and should not be lower than that. The recommended time, again, is 15 to 30 seconds.





10. A TB patient was discharged in the hospital. A UV Lamp was placed in the room where he stayed for a week. What type of disinfection is this?

A. Concurrent disinfectionB. Terminal disinfectionC. Regular disinfectionD. Routine disinfection

Rationale: b. Terminal disinfection refers to practices to remove pathogens that stayed in the belongings or immediate environment of an infected client who has been discharged. An example would be killing airborne TB Bacilli using UV Light. Concurrent disinfection refers to ongoing efforts implented during the client's stay to remove or limit pathogens in his supplies, belongings, immediate environment in order to control the spread of the diseasa. An example is cleaning the bedside commode of a client with radium implant on her cervix with a bleach disinfectant after each voiding.





11. The four major concepts in nursing theory are the

A. Person, Environment, Nurse, HealthB. Nurse, Person, Environment, CureC. Promotive, Preventive, Curative, RehabilitativeD. Person, Environment, Nursing, Health

Rationale: D This is an actual board exam question and is a common board question. Theorist always describes The nursing profession by first defining what is NURSING, followed by the PERSON, ENVIRONMENT and HEALTH CONCEPT. The most popular theory was perhaps Nightingale’s. She defined nursing as the utilization of the persons environment to assist him towards recovery. She defined the person as somebody who has a reparative capabilities mediated and enhanced by factors in his environment. She describes the environment as something that would facilitate the person’s reparative process and identified different factors like sanitation, noise, etc. that affects a person’s reparative state.

Reference: http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories

Nursing Process: Assessment

Core Competency: Personal and Professional DevelopmentCognitive Domain: knowledge

12. The act of utilizing the environment of the patient to assist him in his recovery is theorized byA. NightingaleB. BennerC. SwansonD. King

Rationale: A, Florence nightingale do not believe in the germ theory, and perhaps this was her biggest mistaka. Yet, her theory was the first in nursinc. She believed that manipulation of

http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories



environment that includes appropriate noise, nutrition, hygiene, light, comfort, sanitation etc. could provide the client’s body the nurturance it needs for repair and recovery.Reference: http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories


Core Competency: Environmental Resource ManagementCognitive Domain: knowledge

13. For her, Nursing is a theoretical system of knowledge that prescribes a process of analysis and action related to care of the ill person

A. KingB. HendersonC. RoyD. Leininger

Rationale: C,Remember the word “ THEOROYTICAL “ For Callista Roy, Nursing is a theoretical body of knowledge that prescribes analysis and action to care for an ill person. She introduced the ADAPTATION MODEL and viewed person as a BIOSPSYCHOSOCIAL BEINC. She believed that by adaptation, Man can maintain homeostasis.Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories:

Nursing Process: AssessmentCore Competency: Personal and Professional DevelopmentCognitive Domain: knowledge

14. According to her, Nursing is a helping or assistive profession to persons who are wholly or partly dependent or when those who are supposedly caring for them are no longer able to give care.

A. HendersonB. OremC. SwansonD. Neuman

Rationale: B In self-care deficit theory, Nursing is defined as A helping or assistive profession to person who are wholly or partly dependent or when people who are to give care to them are no longer availabla. Self-care, are the activities that a person do for himself to maintain health, life and well-being.

Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories











Core Competency: Safe and quality nursing careCognitive Domain: knowledge

15. Nursing is a unique profession, Concerned with all the variables affecting an individual’s response to stressors, which are intra, inter and extra personal in nature.

A. NeumanB. JohnsonC. WatsonD. Parse

Rationale: A, Neuman divided stressors as either intra, inter and extra personal in natura. She said that NURSING is concerned with eliminating these stressors to obtain a maximum level of wellness. The nurse helps the client through PRIMARY, SECONDARY AND TERTIARY prevention modes. Please do not confuse this with LEAVELL and CLARK’S level of prevention.



Core Competency: Personal and Professional Development

Cognitive Domain: Knowledge

16. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health that he would perform unaided if he has the necessary strength, will and knowledge, and do this in such a way as to help him gain independence as rapidly as possibleA. HendersonB. AbdellahC. LevinD. Peplau

Rationale: A This was an actual board question. Remember this definition and associate it with Virginia Henderson. Henderson also describes the NATURE OF NURSING theory. She identified 14 basic needs of the client. She describes nursing roles as SUBSTITUTIVE : Doing everything for the client, SUPPLEMENTARY : Helping the client and COMPLEMENTARY : Working with the client. Breathing normally, Eliminating waste, Eating and drinking adquately, Worship and Play are some of the basic needs according to her.Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories









Cognitive Domain: comprehension

17. Caring is the essence and central unifying, a dominant domain that distinguishes nursing from other health disciplines. Care is an essential human need.

A. BennerB. WatsonC. LeiningerD. Swanson

Rationale: C There are many theorist that describes nursing as CARA. The most popular was JEAN WATSON'S Human Caring Model. But this question pertains to Leininger's definition of carinc. CUD I LIE IN GER? [ Could I Lie In There ] Is the Mnemonics I am using not to get confused. C stands for CENTRAL , U stands for UNIFYING, D stands for DOMINANT DOMAIN. I emphasize on this matter due to feedback on the last June 2006 batch about a question about CARINC.


Nursing Process: AssessmentCore Competency: Personal and Professional DevelopmentCognitive Domain: Knowledge

18. Caring involves 5 processes, KNOWING, BEING WITH, DOING FOR, ENABLING and MAINTAINING BELIEB.


Rationale: D Caring according to Swanson involves 5 processes. Knowing means understanding the client. Being with emphasizes the Physical presence of the nurse for the patient. Doing for means doing things for the patient when he is incapable of doing it for himselb. Enabling means helping client transcend maturational and developmental stressors in life while Maintaining belief is the ability of the Nurse to inculcate meaning to these events.Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories

Nursing Process: AssessmentCore Competency: Personal and Professional DevelopmentAffective Domain: characterization







19. Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit.


Rationale:B The deepest and spiritual definition of Caring came from Jean watson. For her, Caring expands the limits of openess and allows access to higher human spirit.Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentals-of-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursing-test-i-history-concepts-and-theories

Nursing Process: AssessmentCore Competency: Personal and Professional DevelopmentAffective Domain: organization

20. Caring means that person, events, projects and things matter to peopla. It reveals stress and coping options. Caring creates responsibility. It is an inherent feature of nursing practica. It helps the nurse assist clients to recover in the face of the illness.A. BennerB. WatsonC. LeiningerD. Swanson

Rationale: A I think of CARE BEAR to facilitate retainment of BENNER. As in, Care Benner. For her, Caring means being CONNECTED or making things matter to peopla. Caring according to Benner give meaning to illness and re establish connection.




Affective Domain: valuing 21. An ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the heat. The nurse interprets this nonverbal behavior as:

a. Reflecting a cultural valueb. An acceptance of the treatmentc. The client is agreeable to the required procedured. The client understands the preoperative procedures







Rationale: Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of agreement with the speaker, an acceptance of the treatment, or an understanding of the procedure.

Reference: Giger, J., Davidhizar, R (2006) Transcultural nursing assessment and intervention (6th ed., p. 15)

Nursing Process: AssessmentCore Competency: CommunicationCognitive Domain: Knowledge

22. When communicating with a client who speaks a different language, the best practice for a nurse is to:

a. Speak loudly and slowlyb. Stand close to the client and speak slowlyc. Arrange for an interpreter when communicating with the clientd. Speak to the client and family together to increase the chances that the topic will be

understood.

Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language.

Reference: Jarvis, C. (2008) Physical Examination and health assessment (5th ed., pp71-72)

Lewis, S., Heitkernper, M., Dirksen, S., & Bucher, L. (2007) Medical Surgical nursing: assessment and management of clinical problesm (7th ed.,p36)

Nursing Process: InterventionCore Competency: Collaboration adn teamworkCognitive Domain: Application

23. Which of the following meal trays would be appropriate for a nurse to deliver to a client of orthodox Judaism faith who follows a kosher diet

a. Pork roast, rice, vegetables, mixed fruit, milkb. Crab salad on a croissant, vegetables with dip, potato salad, milkc. Sweet and sour chicken with rice and vegetables, mixed fruit, juiced. Fettuccini alfredo with shrimp and vegetables, salad, mixed fruit, iced tea

Rationale: Orthodox Judaism believers adhere to dietary kosher laws. In this religion, the dairy meat combination is unacceptabla. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered.

Reference: Joanna Hayden; Introduction to health behavior theory

Nursing Process: InterventionCore Competency: Ethico moral responsibilityCognitive Domain: Analysis

24. When counseling a female arnish client, a nurse should:a. Speak only to the husbandb. Use complex medical terminology

c. Avoid using scientific or medical jargond. Stand close to the client and speak loudly

Rationale: Complex scientific or medical terminology should be avoided when counseling an arnish client ( or any client). When counseling a female arnish client, most often the husband and wife will want to discuss health care option together. Standing close and speaking loudly is inappropriate in most counseling situations.

Reference: Maurer,B. , & Smith, C. (2009) Community/ Public health nursing practices: health for families and population (4th ed., pp278-281,294

Nursing Process: Intervention

Core Competency: Communication

Cognitive Domain: Knowledge

25. A nurse is planning to instruct the Hispanic-American client about nutrition and dietary restrictions. When developing the plan, the nurse is aware that this ethnic group

a. Enjoys a food as long as it is not spicyb. Primarily eats raw fishc. Enjoys eating red meat such as steaksd. Views food as a primary of socialization

Rationale: D. Hispanic foods are rich in color, flavor, texture and spiciness. In the Hispanic-American culture any occasion is seen as a time to celebrate with food and enjoy the companionship of family and friends.

Reference: Thomas Weaver; Handbook of Hispanic Cultures in the United States: Anthropology (p78)


Core Competency: Ethico moral responsibility

Cognitive Domain: Analysis

26. A nurse is planning care for a hospitalized male holdaper who is an Orthodox Jew. Which action by the nurse is appropriate for this client?

a. Instruct the nursing assistant to avoid exposing and washing the client’s feet.b. Assign a male nursing assistant to help the client with his personal care.c. Ensure that medications and food are given to the client with only the right hand.d. Expect that the client will refuse care unless provided by a female staff member.

Rationale: B. Some culture such as Orthodox Jews, consider touching unrelated males and females forbidden. Whenever possible, personal care should be provided by caregivers who are the same gender as the client

Reference: Perry, A., &Potter, P. (2010) Clinical nursing skills and techniques (7th ed., p424)

Nursing Process: Intervention

Core Competency: Ethico moral responsibilityCognitive Domain: Analysis

27. A nurse is caring for an Eastern Orthodox client. During Lent, the nurse should offer the client which of the following dietary choices?

a. Tossed green saladb. Chicken noodle soupc. Steak with baked potatod. Corned beef

Rationale: During Lent all animal products, including dairy products, are forbidden in the Eastern Orthodos religion. Therefore, option b,c,d are incorrect

Reference: Perry, A., &Potter, P. (2010) Clinical nursing skills and techniques (7th ed., p1096)

Nursing Process: InterventionCore Competency: Management of resources and environmentCognitive Domain: Comprehension

28. A nurse is implementing the complementary thereapy of therapeutic touch when caring for clients. When performing therapeutic touch, the nurse should:

a. Apply heating pads to the backb. Vigorously massage bony prominences.c. Position hands 2 to 4 inches from the bodyd. Position hands directly on the client’s skin.

Rationale: C. During therapeutic touch, nurses use their hands to assess the client’s energy field. Hands are positioned 2 to 4 inches from the body. The energy field is assessesed for bilateral similarities or differences in the flow of energy. The next step is cleaning and balancing the energy field. Nurses then redirect energy through their own intentionallyd. The session ends with a smoothing of the energy. The session ends with a smoothing of energy. Therefore, option a,b,dare incorrect

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp.12-13)

Nursing Process: InterventionCore Competency: Safe and Quality nursing careCognitive Domain: Application

29. A nurse is caring for a chinese client during labor. The cliend is exhibiting facial grimacing and appears to be in pain. When the nurse offers the client an analgesic. The client refuses. The nurse’s initial response should be which of the following?

a. Administering an analgesicb. Offer an analgesic painc. Check the client’s vital signsd. Document the client’s refusal.

Rationale: Chinese women may not exhibit reactions to pain, although it is acceptable to exhibit pain during childbirtd. In the Chinese cultura. It is considered impolite to accept something when it is first offered; therefore, pain interventions may need to be offered more than once.

Reference: Giger, J., Davidhizar, R (2006) Transcultural nursing assessment and intervention (6th ed., p. 446-447)

Nursing Process: AssessmentCore Competency: Quality improvementCognitive Domain: Comprehension

30. The student nurse which is guided by her instructor understand that which of the following statements regarding herbal and health therapies is correct?

a. Zinc is used for insomiab. Ginger is used to improved memoryc. Echinacea is used for erectiled. Black cohosh produces estrogen-like effects.

Rationale: D. Black cohosh produces estrogen-like effects. Zinc stimulates immune system and is used for its antiviral properties. Ginger is used for nausea and vomiting, and Echinacea stimulates immune system.

Reference: Black,. J., & Hawks, J. (2009). Medical-surgical nursing:Clinical management for positive outcomes (8th ed.., p. 1797)

Nursing Process: EvaluationCore Competency: Collaboration and teamworkCognitive Domain: Comprehension

31. These are roles and functions of the nurse, EXCEPT:A. CaregiverB. CommunicatorC. TeachersD. Lawyer

ANSWER: DRATIONALE: Lawyer conducts lawsuits for clients or to advice as legal rights and obligation in other matters. Caregiver role has traditionally included those activities that assist the client physically and psychologically while preservation client’s dignity. Communicator role identify client problems and then communicate these verbally or in writing to other members of the health team. Teacher’s role helps clients learn about their health and the health care procedures they need to perform to restore or maintain their healtd. REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY:TAXONOMY:NURSING PROCESS:

32. Which of the following is an example of continuing education for nurses?a. Attending the hospital’s orientation programb. Talking with a company representative about a new piece of equipmentc. Completing a workshop on ethical aspects of nursingd. Obtaining information about the facility’s new computer charting system.

ANSWER: CRATIONALE: continuing education refers to formalized experiences designed to enlarge the knowledge or skills of practitioners. The other answers are examples of in – service education, which is designed to upgrade the knowledge or skills of current employees with regard to the specific setting and is usually less formal in presentation.REFERENCE:CORE COMPETENCY: safe Effective Care EnvironmentTAXONOMY: CD – AnalysisNURSING PROCESS: Not Applicable

33. Which of the following women made significant contributions to the nursing care of soldiers during Civil War? Select all that apply.

a. Harriet Tubmanb. Florence Nightingalec. Fabiolad. Dorothea Dixe. Sojourner Truth

ANSWER: B & CRATIONALE: Florence Nightinale, contributed to the nursing care of soldiers in the Crimean war. C – Fabiola, used her wealth to provide houses of caring and healing during the Roman Empira. REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY:TAXONOMY: CD - KnowledgeNURSING PROCESS: Not Applicable

34. Which of the following activities best represents health promotion?a. Administering immunizationsb. Giving a bathc. Preventing accidents in the homed. Performing diagnostic procedures

ANSWER: C RATIONALE: Health Promotion focuses on maintaining normal status without consideration of diseases. A – is an example of illness prevention. B – is aesthetic (not needed for health promotion or disease prevention). D – focuses on disease detection.REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY:TAXONOMY: CD – KnowledgeNURSING PROCESS: Not Applicable

35. Who are America’s first two trained nurses?a. Barton and waldb. Dock and sangerc. Richards and Mahoneyd. Henderson and Breckinridge

ANSWER: C

RATIONALE: Linda Richards was America’s first trained nurse, and Mary Mahoney was America’s first trained nurse.REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY:TAXONOMY: CD – KnowledgeNURSING PROCESS: Not Applicable

36. A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands is at which stage of Benner’s states of nursing expertise?

a. Advanced beginnerb. Competentc. Proficientd. Expert

ANSWER: BRATIUONALE: the competent 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands.A – the advanced beginner demonstrates marginally acceptable performance.C – the proficient practitioner has 3 to 5 years of experience and has developed a holistic understanding of the client. D – the expert practitioner demonstrates highly skilled intuitive and analytic ability in new situations.REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORECOMPETENCY: Not ApplicableTAXONOMY: CD – KnowledgeNURSING PROCESS: Not Applicable

37. Which professional organization developed a code for nursing students?a. ANAb. NLNc. AACNd. NSNA

ANSWER: DRATIONALE: the National Student Nurses’ Association developed the Code Of Academic and Clinical Conduct for nursing students in 2001.A – ANA, developed Standards of Nursing Practices.B – NLN, focuses on nursing educationC – the American Association of Colleges of Nursing (AACN), is the national organization that focuses on the advancement and maintenance of America’s baccalaureate and higher degree nursing education programs.REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY: Record managementTAXONOMY: CD – KnowledgeNURSING PROCESS: Not applicable

38. Which of the following social forces is most likely to significantly impact the future supply and demand for nurses?

a. Agingb. Economicsc. Science/technologyd. Telecommunications

ANSWER: A RATIONALE: All will impact nursing but not necessarily the supply and demand issua. The aging population contributes to more elders needing specialized care (increasing the demand). Fewer nursing faculty to educate students and fewer nurses practicing because of retirement contribute to the decreasing supply. REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY: Quality ImprovementTAXONOMY: CD – Analysis NURSING PROCESS: Not Applicable

39. An 85-year – old client in a nursing home tells a nurse, “Because the doctor was so insistent, I signed the papers for that research study. Also, I was afraid he would not continue taking care of me.” Which client right is being violated?

a. Right not to be harmedb. Right to full disclosurec. Right of privacy and confidentialityd. Right of self – determination

ANSWER: DRATIONALE: the right of self – determination means that subjects feel of constraints, coercion, or may undue influence to participate in a study. There is not enough information given to indicate if any of the other rights have been violated.REFERENCE: Fundamentals of nursing 8th EDITION, Kozier & ERB’SCORE COMPETENCY: Safe, Effective Care EnvironmentTAXONOMY: CD – ComprehensionNURSING PROCESS: Diagnosis

40. Order: To infuse Esmolol Hcl 5g in 500 ml D5W. Titrate 50 –100 mcg/kg/min to maintain the systolic blood pressure at 120 mm hc. Weight 140 lb

a. What is the concentration of the solution in mcg/ml?b. How many mcg/min will administer the ordered range of titration? Lower (50mcg/kg/min)Upper (100mcg/kg/min)c. How many ml/hr or gtt/min will administer the ordered range of titration?Lower:Upper:d. What is the titration (concentration) factor in mcg/gtt?e. The present systolic blood pressure reading is 160 mm hc. Increase the gtt/min by 5 gtt. How many mcg/min will the patient now be receiving?

Given:Esmolol Hcl 5g in 500ml D5WTitrate 50 –100 mcg/kg/minSystolic blood pressure at 120mm hg

A. Equivalent: 5g = 500 ml 1 mg = 1000 mcg

Conversion Equation:

1 ml x 5 g/500ml x 1000mcg/1mg =

41. A male patient is to be discharged with a prescription for an analgesic that is a controlled substanca. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?

a. Within 1 month

b. Within 3 months

c. Within 6 months

d. Within 12 months

Answer: C

Rationale:

In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.

Reference:

Murray, S., Mckinney, E., and Gorrie, T.(2002). Fundamentals of nursing care plans 8th edition; Philadelphia: W. B. Saunders.

Nursing Process: Assessing

Core Competency: Safe and quality of nursing

Cognitive Domain: Application

42. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?

a. The bell detects high-pitched sounds best

b. The diaphragm detects high-pitched sounds best

c. The bell detects thrills best

d. The diaphragm detects low-pitched sounds best

Answer: B

Rationale:

The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.

Reference:





43. When examining a patient with abdominal pain the nurse in charge should assess:

a. Any quadrant first

b. The symptomatic quadrant first

c. The symptomatic quadrant last

d. The symptomatic quadrant either second or third

Answer: C

Rationale:

The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.

Reference:





44. The nurse in charge measures a patient’s temperature at 102 degrees B. what is the equivalent Centigrade temperature?

a. 39 degrees C

b. 47 degrees C

c. 38.9 degrees C

d. 40.1 degrees C

Answer: C

Rationale:

To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees – 32) x 5/9 C degrees = (102 – 32) 5/9 + 70 x 5/9

38.9 degrees C

Reference:





45. A female patient with a terminal illness is in denial. Indicators of denial include:

a. Shock dismay

b. Numbness

c. Stoicism

d. Preparatory grief

Answer: A

Rationale:

Shock and dismay are early signs of denial-the first stage of grieb. The other options are associated with depression—a later stage of grieb.

Reference:





46. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

a. Prolonged half-life

b. Poor absorption

c. Potential for drug dependence

d. Potential for hepatotoxicity

Answer: C

Rationale:

Patients can become dependent on barbiturates, especially with prolonged usa. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-lifa. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.

Reference:





47. Nurse Brenda is teaching a patient about a newly prescribed druc. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?

a. Decreased plasma drug levels

b. Sensory deficits

c. Lack of family support

d. History of Tourette syndrome

Answer: C

Rationale:

Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the druc. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.

Reference:





48. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?

a. “Everything will be fina. Don’t worry.”

b. “Read this manual and then asks me any questions you may have.”

c. “Why don’t you listen to the radio?”

d. “Let’s talk about what’s bothering you.”

Answer: D

Rationale:

Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.

Reference:





49. Which of the following planes divides the body longitudinally into anterior and posterior regions?

a. Frontal plane

b. Sagittal plane

c. Midsagittal plane

d. Transverse plane

Answer: A

Rationale:

Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plana. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

Reference:





50. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?

a. Restlessness

b. Pale, warm, dry skin

c. Heart rate of 110 beats/minute

d. Urine output of 30 ml/hour

Answer: A

Rationale:

Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritabla. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

Reference:





51. To evaluate a client's chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?

A. Skin turgorB. HydrationC. OrgansD. Temperature

Rationale: The purpose of deep palpation, in which the nurse indents the client's skin approximately 1½" (3.8 cm), is to assess underlying organs and structures, such as the

kidneys and spleen. Skin turgor, hydration, and temperature can be assessed by using light touch or light palpation

Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 1029-1084

Core Competency Standard: Safe & quality nursing practiceNursing Process: EvaluationCognitive Domain: Knowledge

52. One of the nursing fundamentals questions is about giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:

A. 15 degrees.B. 30 degrees.C. 45 degrees.D. 90 degrees.

Rationale: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection

Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 705-709Core Competency Standard: Quality improvementNursing Process: ImplementationCognitive Domain: Application

53. A client, age 43, has no family history of breast cancer or other risk factors for this diseasa. The nurse should instruct her to have a mammogram how often

A. Once, to establish a baselineB. Once per yearC. Every 2 yearsD. Twice per year

Rationale: A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. After age 50, the client should have a mammogram every year


Core Competency Standard: Safe & quality nursing practiceNursing Process: ImplementationCognitive Domain: Application

54. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be: A. allowing the family to see a newly admitted client.

B. ambulating the client in the hallway.C. administering pain medicationD. placing wrist restraints on the client.

Rationale: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 956-960

Core Competency Standard: Management of resources & environmentNursing Process: ImplementationCognitive Domain: Application

55. Which element in the circular chain of infection can be eliminated by preserving skin integrity?

A. HostB. ReservoirC. Mode of transmissionD. Portal of entry

Rationale: In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.


Core Competency Standard: ResearchNursing Process: DiagnosisCognitive Domain: Knowledge

56. Which of the following will probably result in a break in sterile technique for respiratory isolation?

A. Opening the patient’s window to the outside environmentB. Turning on the patient’s room ventilatorC. Opening the door of the patient’s room leading into the hospital corridorD. Failing to wear gloves when administering a bed bath

Rationale: Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain closed. However, the patient’s room should be well ventilated, so opening the window or turning on the ventricular is desirabla. The nurse does not need to wear gloves for respiratory isolation, but good hand washing is important for all types of isolation.



http://nursingcrib.com/continuing-education/chain-of-infection/

57. Which of the following patients is at greater risk for contracting an infection? A. A patient with leukopeniaB. A patient receiving broad-spectrum antibioticsC. A postoperative patient who has undergone orthopedic surgeryD. A newly diagnosed diabetic patient

Rationale: Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking broad-spectrum antibiotics might actually reduce the infection risk.


Core Competency Standard: Research Nursing Process: EvaluationCognitive Domain: Knowledge

58. Effective hand washing requires the use of: A. Soap or detergent to promote emulsificationB. Hot water to destroy bacteriaC. A disinfectant to increase surface tensionD. All of the above

Rationale: Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns.



59. After routine patient contact, hand washing should last at least: A. 30 secondsB. 1 minuteC. 2 minuteD. 3 minutes

Rationale: Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission.


Core Competency Standard: Quality improvementNursing Process: ImplementationCognitive Domain: Knowledge

60. Which of the following procedures always requires surgical asepsis? A. Vaginal instillation of conjugated estrogenB. Urinary catheterizationC. Nasogastric tube insertionD. Colostomy irrigation

Rationale: The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state.



61. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?

A. Using sterile forceps, rather than sterile gloves, to handle a sterile itemB. Touching the outside wrapper of sterilized material without sterile glovesC. Placing a sterile object on the edge of the sterile fieldD. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a

sterile container

Rationale: The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.

Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 1020-1023Core Competency Standard: Safe & quality nursing practiceNursing Process: ImplementationCognitive Domain: Application

62. All of the following statement are true about donning sterile gloves except: A. The first glove should be picked up by grasping the inside of the cufb. B. The second glove should be picked up by inserting the gloved fingers under the cuff

outside the glove.C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and

pulling the glove over the wristD. The inside of the glove is considered sterile

Rationale: The inside of the glove is always considered to be clean, but not sterile.



REFERENCE: FUNDAMENTALS OF NURSING BY KOZIER AND ERB’S

63. A client with status asthmaticus is in severe respiratory distress. The nurse should maintain the client in which position?

a) Sitting uprightb) Side-lyingc) Supined) Prone

RATIONALE: A. a client in status asthmaticus should be placed in the position that promotes air exchanga. Sitting upright eases the motion of the diaphragm and promotes air exchange.NURSING PROCESS: interventionCORE COMPETENCY: Safe and Quality nursing careCOGNITIVE DOMAIN: analysis

64. A client undergoes an open reduction and internal fixation to treat a fractured right hip. Five hours after surgery, the nurse should maintain the client’s affected leg in which position?

a) External rotationb) Abductionc) Flexiond) Hyperextension

RATIONALE: B. after surgery for a fractured hip, the affected leg should be placed in abduction, using an abduction splint or pillows placed between the legs to separate them. The other options may cause dislocation.NURSING PROCESS: interventionCORE COMPETENCY: legal responsibilityCOGNITIVE DOMAIN: application

A pregnant client is in the first stage of labor. The nurse should include which of the following in the client’s plan of care during this stage?

a) Encourage the client to lie on her left sideb) Instruct the client to ambulatec) Urge the client to accept pain medicationd) Advise the client to use learned breathing techniques

RATIONALE: B. during the first stage of labor, ambulation helps to stimulate labor. Lying down (option A) and taking pain medication (option C) may slow early labor. The client should use learned breathing techniques only when she can no longer talk during contractions (option D).

NURSING PROCESS: planningCORE COMPETENCY: Safe and Quality nursing careCOGNITIVE DOMAIN: application

65. After a tonsillectomy and adenoidectomy, a child returns to the pediatric unit. Until fully awake, the child should be maintained in which position?

a) Side-lyingb) Supinec) Knee-chestd) Lithotomy

RATIONALE: A. side lying position help prevent aspiration. The other options don’t provide this advantage.NURSING PROCESS: interventionCORE COMPETENCY: personal and professional developmentCOGNITIVE DOMAIN: comprehension

66. Which assessment finding would indicate that a client’s abdominal ascites are decreasing?

a) The amount of ankle edema remains the sameb) Abdominal skin becomes shinierc) Urine output per void increasesd) The pulse rate increases over time

RATIONALE: C. increased urine output means ascetic fluid is being absorbed into the circulation and then excreted. As this fluid is absorbed, ankle edema should decreased, not remain the same (option A), and abdominal skin should become less shiny, not shinier (option B). with decreasing ascites, lower fluid volume would cause the pulse rate to slow, not to increased (option D)NURSING PROCESS: assessmentCORE COMPETENCY: health educationCOGNITIVE DOMAIN: comprehension

67. Based on multiple referrals, the nurse determines that childhood injuries are increasing in the community in which she practices. The first step the nurse would take in developing an educational program is:

a) Assessing for a decrease in referrals following a pediatric safety classb) Assessing the strengths and needs of the community while identifying barriers to

learningc) Choosing a health promotion or health belief model as a frameworkd) Developing and implementing a specific plan to decrease childhood injuries

RATIONALE: B. following the identification of a learning need, the first step is to assess the strengths and need of the community while identifying barriers to learningNURSING PROCESS: planningCORE COMPETENCY: Safe and Quality nursing careCOGNITIVE DOMAIN: analysis

68. Although a client’s physiologic response to a health crisis is important to the health outcome, which of the following nursing interventions also must be addressed?

a) Teach the family how to care for the clientb) Help the client effectively cope with the crisisc) Maintain I.V access, medications and dietd) Teach the client basic information about the illness

RATIONALE: B. although all of the answers are important in the care of the client, if the individual can’t cope with the emotional, spiritual and psychological aspects of his crisis, the other components of care may be ineffective as wellNURSING PROCESS: interventionCORE COMPETENCY: ethico-moral responsibilityCOGNITIVE DOMAIN: application

69. Nursing management of a client with a pulmonary embolism focuses on which of the following actions?

a) Assessing oxygenation statusb) Monitoring the oxygen delivery devicec) Monitoring for other sources of clotsd) Determining whether the client requires another ventilation-perfusion scan

RATIONALE: A. pulmonary embolism focuses on assessing oxygenation status and ensuring treatment is adequata. Option B, C and D are other nursing responsibilities, but they aren’t the focus careNURSING PROCESS: interventionCORE COMPETENCY: quality improvementCOGNITIVE DOMAIN: application

70. A client describes a foul odor from his cast. Which of the following responses or interventions would be the most appropriate?

a) Assess further bec. This may be a sign of infectionb) Teach him proper cast care, including hygiene measuresc) This is normal, especially when a cast is in place for a few weeksd) Assess further bec. This may be a sign of neurovascular compromise

RATIONALE: A. a foul odor from a cast may be a sign of infection. The nurse needs to assess for fever, malaise and possibly an elevation in WBC. Odor from a cast is never normal, and it isn’t a sign of neurovascular compromise which would include decreased pulses, coolness and paresthesiaNURSING PROCESS: assessmentCORE COMPETENCY: Safe and Quality nursing careCOGNITIVE DOMAIN: analysis

71. Which of the following chronic complications is associated with diabetes mellitus?

a) Dizziness, dyspnea on exertion and anginab) Retinopathy, neuropathy and coronary artery disease (CAD)c) Leg ulcers, cerebral ischemic event and pulmonary infarctsd) Fatigue, nausea, vomiting, muscle weakness and cardiac arrhythmias

RATIONALE: B. retinopathy, neuropathy and CAD are all chronic complications of DM. Dizziness, dyspnea on exertion and angina are symptoms of aortic valve stenosis. Hyperparathyroidism causes fatigue, nausea, vomiting, muscle weakness and cardiac arrhythmias. Leg ulcers, cerebral ischemic events and pulmonary infarcts are complications of sickle cell anemia.NURSING PROCESS: analysisCORE COMPETENCY: health educationCOGNITIVE DOMAIN: knowledge

72. Which of the following interventions would help a client diagnosed with Alzheimer’s disease perform activity of daily living?

a) Have the client perform all basic care without helpb) Tell the client morning care must be done by 9 amc) Give the client a written list of activities he’s expected to dod) Encourage the client and give ample time to complete basic tasks.

RATIONALE: D. client’s w/ Alzheimer’s disease respond to the affect of those around them. A gentle calm approach is comforting and nonthreatening and a tense, hurried approach may agitate the client. The client has problems performing independently. These expectations mat lead to frustration.NURSING PROCESS: interventionCORE COMPETENCY: Safe and Quality nursing careCOGNITIVE DOMAIN: application

73. Which of the following assessment data should the nurse include when obtaining a review of body systems?

a. The client’s name, address, age, and phone number.b. Brief statement about what brought client to health care provider.c. Information about the client’s sexual performance and preferenced. Client complaints of any chest pain, dyspnea, or abdominal pain.

Answer:dRationale: client complains about chest pain,dysnea, or abdominal pain are consider part of the review of body systems. This portion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac,respiratory,and abdominal. Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: assessmentCognitive Domain: knowledgeCore competency: record management

74. A client has come to the nursing clinic for a comprehension health assessment. Which of the following statements would be the best way to end history interview?

a. “What brought you to clinic today?”b. “Would you describe your overall health as good?”c. “Do you understanding what is happening?”d. Is there anything else you would like to tell me?”

Answer: d

Rationale:By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. Asking about what brought the client here today is an ambiguous question to which the client may answer”may car” or any similarly disingenuous reply.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: AssessmentCognitive Domain: ComprehensionCore competency: record management75. For which of the following time periods would the nurse notify the physician that the client had no bowel sounds?

a. 2 minutesb. 3 minutesc. 4 minutesd. 5 minutes

Answer: d Rationale:To completely determine that bowel sounds are absents, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2,3 or 4 minutes is too short a period to arrive at his conclusion.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process; ImplementationCognitive Domain: KnowledgeCore competency: Health education

76. Which of the following area is the best area for auscultating the apical pulse?a. Aortic archb. Pulmonic areac. Tricuspid aread. Mitral area

Answer: dRationale: The mitral area, the fifth ICS at the left midclavicular line and also known as left ventricular are or the apical area, is the best area for auscultating the apical pulse.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: assessmentCognitive Domain: KnowledgeCore competency: Health education77. Which of the following point should the nurse remember when performing a breast examination on a female client?

a. One half of all breast cancer deaths are women between the ages of 35 and 45.b. The “tail of Spence” area must be included in self-examination.c. The position of choice for the breast examination is supine.d. A pad should be placed under the opposite scapula of the breast being palpated.

Answer: b Rationale: The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. This are must also be included in breast self-examination.Reference: Lippincott’s Review Series. 3rd edition copyright 2001 by Lippincott Williams & Wilkins.Nursing process: assessmentCognitive Domain: knowledge

Core competency: communication

78. To prevent client discomfort and injury during oroscopic examination, which of the following should be avoided?

a. Tipping the client’s head away from the examiner and pulling the ear up and back.b. Inserting the otoscope inferiorly into the distal portion of the external canalc. Inserting the otoscope superiorly into the proximal two thirds of the external canal.d. Bracing the examiner’s hand against the client’s head.

Answer: cRationale: In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two thirds. It is important to avoid thesethese structures during the examination.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: AssessmentCognitive Domain: KnowledgeCore competency: health education

79. When assessing the lower extremities for arterial function, the nurse should include which of the following.

a. assessing the medial malleoli for pitting edema.b. Performing the Allen’s testc. Assessing for the Homan’s signd. Palpating the pedal pulses

Answer: d Rationale:Palpating the client’s pedal pulses assist in determining is arterial blood suppy to the lower extremities id sufficient.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process AssessmentCognitive Domain: knowledgeCore competency: safe and quality nursing care80. Which of the following examinations requires the nurse to wear gloves?

a. Oralb. Ophthalmicc. Breastd. Integumentary

Answer: aRationale: Gloves should be worn any time there is a risk of exposure to the client’sblood or body fluids.Oral,rectal and genital examinations require gloves because they involve contract with body fluids.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: assessmentCognitive Domain: knowledgeCore competency: health education81. To ensure a client’s safety during the Romberg test, which of the following measures should the nurse take?

a. Stand close to provide support.b. Allow the client keel his eyes open.c. Let the client spread the feet apart

d. Have the client hang on to a piece of furniture.Answer:a Rationale:During the Romberg test, the client is asked to stand with feet together and eyes shut and still maintain balance with a minimum of sway. If the client loses his balance, the nurse standing close support, such as having an arm close around his shoulder, can prevent a fall.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: AssessmentCognitive Domain: ImplementationCore competency: safely and quality nursing care82. When percussing a client’s chest, the nurse would expect to find which of the following as normal signs over the client’s lungs?

a. Tympanyb. Resonancec. Dullnessd. Hyper resonance

Answer: bRationale: Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration.Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.Nursing Process: AssessmentCognitive Domain: KnowledgeCore competency: health education

83. The nurse is evaluating a client’s auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

a. Whispered voice testb. Weber’s testc. Watch tick testd. Rinne test

Rationale: D The Rinne test compares air conduction to bone in both ears. The whispered voice test evaluates low pitched sounds, and the watch tick test assess high-pitched sounds. Both tests assess gross hearinc. The weber test evaluates bone conduction.

Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: Evaluation

Core Competency Standard: Safe and quality nursing care

Cognitive Domain

84. The nurse is changing a client’s dressinc. Which observation of the wounds warrants immediate physician notification?

a. Approximated wound edgesb. Yellow purulent drainagec. Sutures in placed. Pink granulation

Rationale: B Yellow purulent drainage suggests infection, the nurse report this finding to the physician immediately and obtain a culture as ordered. The other options represent normal findings for a wound.



Core Competency Standard: Safe and quality nursing care

Cognitive Domain

85. What is one disadvantage of using the rectal route?

a. It can cause orthostatic hypotensionb. It can cause hypersensitivity to the drug.c. It can result in incomplete drug absorption.d. It can cause rectal tears.

Rationale: C Incomplete drug absorption is a disadvantage of rectal drug administration. The drug itself, not the way in which it is administered may cause orthostatic hypotension or hypersensitivity. If inserted properly, drugs won’t cause rectal tears.Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: EvaluationCore Competency Standard: Safe and quality nursing careCognitive Domain86. To evaluate a client’s posterior pulse, where should the nurse palpate?

a. Medially in the antecubital spaceb. Midway between the superior iliac spine and symphysis pubisc. On the inner aspect of the ankle, below the medial malleolusd. Along the top of the foot, over the in step

Rationale: C To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluates the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral; and along the top of the foot, over the instep, to evaluate the dosales pedis pulse.Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: EvaluationCore Competency Standard: Safe and quality nursing careCognitive Domain

87. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

a. Impaired gas exchangeb. Impaired oral mucous membranesc. Imbalanced nutrition: Less than body requirementsd. Activity intolerance

Rationale: A although all of the nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the nursing diagnosis with priority for a client with P. carinii pneumonia. Airway, breathing, circulation tops the priority.


Nursing Process: DiagnosisCore Competency Standard: Safe and quality nursing careCognitive Domain

88. After assessing an adolescent with sickle cell anemia, the nurse formulates a nursing diagnosis of impaired skin integrity. Which assessment finding best supports this nursing diagnosis

a. Swelling of the hands and feetb. Petechiaec. Leg ulcersd. Hemangiomas

Rationale: C In sickle cell anemia, sickling RBC leads to increased blood viscosity and impaired circulation. Diminished peripheral circulation makes the adolescent or adult with sickle cell anemia susceptible to chronic leg ulcers.Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: Assessment/ DiagnosisCore Competency Standard: Safe and quality nursing careCognitive Domain/ Analysis

89. When a preschooler’s family displays high levels of mistrust, monitors everyone’s performance, wants high level of information and ask rule changes, which strategy would be inappropriate?

a. Ask their opinion and use their suggestions.b. Be positive about building a trusting relationshipc. Be flexible regarding rulesd. Show support while controlling the care of the child

Rationale: D When a family shows high levels of mistrust, monitors everyone’s performance, requires high level of information, and requests rule changes, the nurse should attempt to build a partnership with the family to reach the goal of mutually caring for the child. Attempting to control care with this family will alienate the family, stress the relationship, and be counterproductive for the child. Good strategies for working with this family would be to ask their opinion, use their suggestions, be positive about building a trusting relationship.Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: Planning Core Competency Standard: Safe and quality nursing careCognitive Domain/Application90. The nurse is developing a care for a client with anorexia nervosa. Which action should the nurse include in the plan?

a. Restrict visits with the family until the clients begins to eat.b. Provide privacy during meals.c. Set up a strict eating plan for the client.d. Encourage the client to exercise, which will reduce her anxiety.

Rationale: C Establishing a consistent eating plan and monitoring the clients weight are important for this disorder. The family should be included in the clients cara. The clients should be monitored during meals- not given privacy. Exercise must be limited and supervised.Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: Planning Core Competency Standard: Safe and quality nursing careCognitive Domain/Application91. One minute after birth, a neonate has an apgar of 7. What should the nurse do.

a. Administer oxygen via nasal prongs as ordered.b. Begin cardiopulmonary resuscitation(CPR)c. Stimulate breathing by rubbing the neonate's back.d. Encourage the mother to hold the neonate close.

Rationale: C An apgar scoare of 5 to 7 indicates mild respiratory depression To correct this problem, the nurse should stimulate breathing by rubbing the neonates back or by gently but firmly slapping the neonates soles. The nurse should also provide o2 but should administer it by bag and facemask rather than nasal prongs. The nurse should perform CPR only if the neonates APGAR score is between 0 and 2. The neonate must be stabilized before being held by the mother.Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: ImplementationCore Competency Standard: Safe and quality nursing careCognitive Domain/Analysis92. Which moral principle is the nurse applying by deciding what is best for a client and acting without consulting the individual?

a. Beneficenceb. Paternalismc. Fidelityd. Autonomy

Rationale: B Paternalism is the moral principle applied by nurses and other health care workers when circumstance compel them to decide what is best for a client and to act without consulting the individual. Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

Nursing Process: ImplementationCore Competency Standard: Safe and quality nursing careCognitive Domain/Comprehension

fundamentals of nursing (group 1)-- 92 question

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