1. Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? interventions? A. Providing a back massage B. Feeding a client . Providing hair care !. Providing oral h"giene #. $he nurse is preparing to take vital sign in an alert client admitted to the hospital with deh"dration secondar" to vomiting and diarrhea. %hat is the best method used to assess the client&s temperature? A. 'ral B. A(illar" . )adial !. *eat sensitive tape +. A nurse obtained a client&s pulse and found the rate to be above normal. $he nurse document this ndings asA. $ach"pnea B. *"perp"re(ia . Arrh"thmia !. $ach"cardia . %hich of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair? A. Bend at the waist and place arms under the client&s arms and lift B. Face the client, bend knees and place hands on client&s forearm and lift . /pread his or her feet apart !. $ighten his or her pelvic muscles 0. A client had oral surger" following a motor vehicle accident. $he nurse assessing the client nds the skin ushed and warm. %hich of the following would be the best method to
take the client&s bod" temperature? A. 'ral B. A(illar" . Arterial line !. )ectal 2. A client who is unconscious needs fre3uent mouth care. %hen performing a mouth care, the best position of a client isA. Fowler&s position B. /ide l"ing . /upine !. $rendelenburg 4. A client is hospitali5ed for the rst time, which of the following actions ensure the safet" of the client? A. 6eep unnecessar" furniture out of the wa" B. 6eep the lights on at all time . 6eep side rails up at all time !. 6eep all e3uipment out of view 7. A walk8in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. $he nurse takes the client&s vital sign hereafter. %hat phrase of nursing process is being implemented here b" the nurse? A. Assessment B. !iagnosis . Planning !. 9mplementation :. 9t is best describe as a s"stematic, rational method of planning and providing nursing care for individual, families, group and communit" A. Assessment B. ;ursing Process . !iagnosis !. 9mplementation 1<. =(change of gases takes place in which of the following organ? A. 6idne" B. >ungs
. >iver !. *eart 11. $he chamber of the heart that receives o("genated blood from the lungs is theA. >eft atrium B. )ight atrium . >eft ventricle !. )ight ventricle 1#. A muscular enlarge pouch or sac that lies slightl" to the left which is used for temporar" storage of food A. @allbladder B. Urinar" bladder . /tomach !. >ungs 1+. $he abilit" of the bod" to defend itself against scientic invading agent such as baceria, to(in, viruses and foreign bod" A. *ormones B. /ecretion . 9mmunit" !. @lands 1. *ormones secreted b" 9slets of >angerhans A. Progesterone B. $ B. $estoster estosterone one . 9nsulin !. *emoglobin 10. 9t is a transparent membrane that focuses the light that enters the e"es to the retina. A. >ens B. /clera . ornea !. Pupils 12. %hich of the following is included in 'rem&s theor"? A. aintenance of a sucient intake of air B. /elf perception . >ove and belongingness !. Ph"siologic needs 14. %hich of the following cluster of data belong to aslow&s hierarch" of needs
A. >ove and belonging B. Ph"siologic needs . /elf actuali5ation !. All of the above 17. $his is characteri5ed b" severe s"mptoms relativel" of short duration. A. hronic 9llness B. Acute 9llness . Pain !. /"ndrome 1:. %hich of the following is the nurse&s role in the health promotion A. *ealth risk appraisal B. $each client to be eCective health consumer . %orksite wellness !. ;one of the above #<. 9t is describe as a collection of people who share some attributes of their lives. A. Famil" B. 9llness . ommunit" !. ;ursing #1. Five teaspoon is e3uivalent to how man" milliliters DmlE? A. +< ml B. #0 ml . 1# ml !. ## ml ##. 17<< ml is e3ual to how man" liters? A. 1.7 B. 17<<< . 17< !. #7<< #+. %hich of the following is the abbreviation of drops? A. @tt. B. @tts. . !p. !. !r. #. $he abbreviation for micro drop is A. gtt B. gtt . mdr !. mgts #0. %hich of the following is the meaning of P);?
A. %hen advice B. 9mmediatel" . %hen necessar" !. ;ow #2. %hich of the following is the appropriate meaning of B)? A. ardiac Board )oom B. omplete Bathroom . omplete Bed )est !. omplete Board )oom #4. 'ne D1E tsp is e3uals to how man" drops? A. 10 B. 2< . 1< !. +< #7. #< cc is e3ual to how man" ml? A. # B. #< . #<<< !. #<<<< #:. 1 cup is e3uals to how man" ounces? A. 7 B. 7< . 7<< !. 7<<< +<. $he nurse must verif" the client&s identit" before administration of medication. %hich of the following is the safest wa" to identif" the client? A. Ask the client his name B. heck the client&s identication band . /tate the client&s name aloud and have the client repeat it !. heck the room number +1. $he nurse prepares to administer buccal medication. $he medicine should be placed A. 'n the client&s skin B. Between the client&s cheeks and gums . Under the client&s tongue
!. 'n the client&s conGunctiva
!. Application of hot compress at the back
+#. $he nurse administers cleansing enema. $he common position for this procedure is A. /ims left lateral B. !orsal )ecumbent . /upine !. Prone
+4. 9t refers to the preparation of the bed with a new set of linens A. Bed bath B. Bed making . Bed shampoo !. Bed lining
++. A client complains of dicult" of swallowing, when the nurse tr" to administer capsule medication. %hich of the following measures the nurse should do? A. !issolve the capsule in a glass of water B. Break the capsule and give the content with an applesauce . heck the availabilit" of a li3uid preparation !. rash the capsule and place it under the tongue +. %hich of the following is the appropriate route of administration for insulin? A. 9ntramuscular B. 9ntradermal . /ubcutaneous !. 9ntravenous +0. $he nurse is ordered to administer ampicillin capsule $9! p.o. $he nurse should give the medication A. $hree times a da" orall" B. $hree times a da" after meals . $wo time a da" b" mouth !. $wo times a da" before meals +2. Back are is best describe asA. aring for the back b" means of massage B. %ashing of the back . Application of cold compress at the back
+7. %hich of the following is the most important purpose of handwashing A. $o promote hand circulation B. $o prevent the transfer of microorganism . $o avoid touching the client with a dirt" hand !. $o provide comfort +:. %hat should be done in order to prevent contaminating of the environment in bed making? A. Avoid fanning soiled linens B. /trip all linens at the same time . Finished both sides at the time !. =mbrace soiled linen <. $he most important purpose of cleansing bed bath isA. $o cleanse, refresh and give comfort to the client who must remain in bed B. $o e(pose the necessar" parts of the bod" . $o develop skills in bed bath !. $o check the bod" temperature of the client in bed 1. %hich of the following techni3ue involves the sense of sight? A. 9nspection B. Palpation . Percussion !. Auscultation #. $he rst techni3ues used e(amining the
abdomen of a client isA. Palpation B. Auscultation . Percussion !. 9nspection +. A techni3ue in ph"sical e(amination that is use to assess the movement of air through the tracheobronchial treeA. Palpation B. Auscultation . 9nspection !. Percussion . An instrument used for auscultation isA. Percussion8hammer B. Audiometer . /tethoscope !. /ph"gmomanometer 0. )esonance is best describe asA. /ounds created b" air lled lungs B. /hort, high pitch and thudding . oderatel" loud with musical 3ualit" !. !rum8like 2. $he best position for e(amining the rectum isA. Prone B. /im&s . 6nee8chest !. >ithotom" 4. 9t refers to the manner of walking A. @ait B. )ange of motion . Fle(ion and e(tension !. *opping 7. $he nurse asked the client to read the /nellen chart. %hich of the following is testedA. 'ptic B. 'lfactor" . 'culomotor !. $rochlear :. Another name for knee8chest position isA. @enu8dorsal B. @enu8pectoral . >ithotom" !. /im&s
0<. $he nurse prepare 9 inGection that is irritating to the subcutaneous tissue. %hich of the following is the best action in order to prevent tracking of the medication A. Use a small gauge needle B. Appl" ice on the
inGection site . Administer at a 0H angle !. Use the I8track techni3ue
Answers and Rationale 1. Answer- !. Providing oral h"giene !oing oral care re3uires the nurse to wear gloves. #. Answer- B. A(illar" A(illa is the most accessible bod" part in this situation. +. Answer- !. $ach"cardia $ach"cardia means rapid heart rate. $ach"pnea D'ption AE refers to rapid respirator" rate. *"perp"re(ia D'ption BE means increase in temperature. Arrh"thmia D'ption E means irregular heart rate. . Answer- B. Face the client, bend knees and place hands on client&s forearm and lift $his is the proper wa" on supporting the client to get up in a chair that conforms to safet" and proper bod" mechanics. 0. Answer- B. A(illar" $aking the temperature via the oral route is incorrect since the client had oral surger". hoice and ! are unnecessar". $aking the temperature via the a(illa is the most appropriate route. 2. Answer- B. /ide l"ing An unconscious client is best placed on his side when doing oral care to prevent aspiration. 4. Answer- . 6eep side rails up at all time Although the other choices seem correct, the" are not the best answer. 7. Answer- A. Assessment Assessment is the rst phase of the nursing process where a nurse collects information about the client. !iagnosis is the formulation of the nursing diagnosis from the information collected during the assessment. 9n Planning, the nurse sets achievable and measurable short and long
term goals. 9mplementation is where nursing care is given. :. Answer- B. ;ursing Process $he statement describes the ;ursing Process. $he ;ursing Process is the essential core of practice for the registered nurse to deliver holistic, patient8focused care. 1<. Answer- B. >ungs 11. Answer- A. >eft atrium $he left atrium receives o("genated blood from the lungs and pumps it to the left ventricle. $he right atrium receives blood from the veins and pumps it to the right ventricle. $he right ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with o("gen. $he left ventricle Dthe strongest chamberE pumps o("gen8rich blood to the rest of the bod", its vigorous contractions create the blood pressure. 1#. Answer- . /tomach 1+. Answer- . 9mmunit" 1. Answer- . 9nsulin $he 9slets of >angerhans are the regions of the pancreas that contain its endocrine cells.Progesterone Dhoice AE is produced b" the ovaries. $estosterone Dhoice BE is secreted b" the testicles of males and ovaries of females. *emoglobin Dhoice !E is a protein molecule in the red blood cells that carries o("gen from the lungs to the bod"&s tissues and returns carbon dio(ide. 10. Answer- . ornea $he cornea is the transparent front part of the e"e that covers the iris, pupil, and anterior chamber. $he cornea is like the cr"stal of a watch. 12. Answer- A. aintenance of a sucient intake of air !orothea 'rem&s /elf8are $heor" dened ;ursing as J$he act of assisting others in the provision and management of self8care to maintain or improve human functioning at home level of eCectiveness.K hoices B,
, and ! are from Abraham aslow&s *ierarch" of ;eeds. 14. Answer- !. All of the above All of the choices are part of aslow&s *ierarch" of ;eeds. 17. Answer- B. Acute 9llness hronic 9llness Dhoice AE are illnesses that are persistent or long8term. 1:. Answer- B. $each client to be eCective health consumer #<. Answer- . ommunit" Famil" is dened as a group consisting t"picall" of parents and children living together in a household. #1. Answer- B. #0 ml 'ne teaspoon is e3ual to 0ml. ##. Answer- A. 1.7 #+. Answer- B. @tts. @tt Dhoice AE is an abbreviation for drop. !p and !r are not recogni5ed abbreviation for measurement. #. Answer- A. gtt #0. Answer- . %hen necessar" P); comes from the >atin Jpro re nataK meaning, for an occasion that has arisen or as circumstances re3uire. #2. Answer- . omplete Bed )est B) means complete bed rest. For more abbreviations, please see this post. #4. Answer- B. 2< 'ne teaspoon DtspE is e3ual to 2< drops DgttsE. #7. Answer- B. #< 'ne cubic centimeter is e3ual to one milliliter. #:. Answer- A. 7 'ne cup is e3ual to 7 ounces. +<. Answer- B. heck the client&s identication band $he identication band is the safest wa" to know the identit" of a patient whether he is conscious or unconscious. Ask the client his name onl" after "ou have checked his 9! band. +1. Answer- B. Between the client&s cheeks and gums +#. Answer- A. /ims left lateral $his position provides comfort to the patient and an eas" access to the natural curvature of the rectum. ++. Answer- . heck the availabilit" of a li3uid preparation $he nurse should check rst if the medication is available in li3uid form before doing hoice A. Placing it under the
tongue is not the intended wa" of administering an oral medication. +. Answer- . /ubcutaneous $he subcutaneous tissue of the abdomen is preferred because absorption of the insulin is more consistent from this location than subcutaneous tissues in other locations. +0. Answer- A. $hree times a da" orall" $9! is the >atin for Jter in dieK which means three times a da". P.'. means per orem or through mouth. +2. Answer- A. aring for the back b" means of massage +4. Answer- B. Bed making +7. Answer- B. $o prevent the transfer of microorganism *and washing is the single most eCective infection control measure. +7. Answer- A. Avoid fanning soiled linens Fanning soiled linens would scatter the lodged microorganisms and dead skin cells on the linens. <. Answer- A. $o cleanse, refresh and give comfort to the client who must remain in bed 1. Answer- A. 9nspection Palpation is a method of feeling with the ngers or hands during a ph"sical e(amination. Percussion is a method of tapping on a surface to determine the underl"ing structure, and is used in clinical e(aminations to assess the condition of the thora( or abdomen. Auscultation Dbased on the >atin verb auscultare Jto listenKE is listening to the internal sounds of the bod", usuall" using a stethoscope. #. Answer- !. 9nspection For abdominal e(am, auscultation is performed before palpation because the act of palpation could change what was auscultated. )emember the mnemonic J98 A8Per8PalK. +. Answer- B. Auscultation . Answer- . /tethoscope 0. Answer- A. /ounds created b" air lled lungs 2. Answer- . 6nee8chest $o assume the genupectoral position the person kneels so that the weight of the bod" is supported b" the knees and chest, with the buttocks raised. $he head is turned to one side and the arms are e(ed
so that the upper part of the bod" can be supported in part b" the elbows. 4. Answer- A. @ait 7. Answer- A. 'ptic ranial ;erve 99 or the optic nerve is tested through the use of the /nellen chart. :. Answer- B. @enu8pectoral 0<. Answer- !. Use the I8track techni3ue
Dur i ngt hepr oc edur e,s k i nandt i s s uear epul l e d andhel dfi r ml ywhi l eal ongne edl ei si ns er t ed i nt ot hemus cl e.Af t ert hemedi c at i oni si nj ec t ed, t hes k i nan dt i s s uear er el e as ed.Th eneedl e t r ac kt hatf or msdur i ngt hi spr oc edur et ak est he s hapeoft hel et t er“ Z, ”whi c hgi v est he pr oc edur ei t sname.Thi szi gz agt r ac kl i nei s wh atp r e v en t sme di c a t i o nf r om l e ak i n gf r o mt h e mus cl ei nt os ur r oundi ngt i s s ue.
