Fundamentals of Nursing (Group 1)-- 92 Question

FUNDAMENTALS OF NURSING 1. What best describes nurses as a care provider? A. Determine client’s need B. Provide direct nursing care C. Help client recognize and cope with stressful psychological situation D. 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. Susceptibility Susceptibility B. Immunity C. Virulence D. 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. 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 3. Diseases that result from changes in the normal structure, from recognizable anatomical changes in an organ or body tissue is termed as A. Functional Functional B. Occupational

C. Inorganic D. Organic

Rationale: d. As d. As the word word implies, ORGANIC Diseases Diseases are those that 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. Reference: Fundamentals of Nur sing, sing, 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 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. Primary B. Secondary C. Tertiary D. 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. 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: comprehension 5. Which is the best way to disseminate information to the public? A. Newspaper Newspaper

B. School bulletins C. Community bill boards D. 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. 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: comprehension 6. Also known as STERILE TECHNIQUE A. Surgical Surgical Asepsis B. Medical Asepsis C. Sepsis D. Asepsis

Rationale: a. Surgical Asepsis is also known as STERILE TECHNIQUE while Medical Asepsis is synonymous with CLEAN TECHNIQUE. Reference: Fundamentals of Nursing, Nursin g, 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 7. This is a process of removing pathogens but not their spores. A. Sterilization Sterilization B. Auto claving C. Disinfection D. 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. 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 8. This is considered as the most important aspect of hand washing A. Time B. Friction C. Water D. 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. 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 9. The minimum time in washing each hand should never be below A. 5 seconds seconds B. 10 seconds C. 15 seconds D. 30 seconds

Rationale: b. Accordin b. According g to Kozier, Kozier, The minimum minimum time required required for watching watching each each hands is 10 seconds and should not be lower than that. The recommended time, again, is 15 to 30 seconds. 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 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 Concurrent disinfection disinfection B. Terminal disinfection C. Regular disinfection D. 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. 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: comprehension 11. The four major concepts in nursing theory are the A. Person, Environment, Environment, Nurse, Health B. Nurse, Person, Environment, Cure C. Promotive, Preventive, Curative, Rehabilitative D. 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 st ate. Reference: http://www.rnpedia.com/home/exams/fundamentals-of-nursingexams/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 Development Cognitive Domain: knowledge 12. The act of utilizing the environment of the patient to assist him in his recovery is theorized by A. Nightingale Nightingale B. Benner C. Swanson D. King Rationale: A, Florence Florence nightingale nightingale do not not believe believe in the germ germ theory, and and perhaps perhaps this was was her biggest mistaka. Yet, her theory was the first in nursinc. She believed that manipulation of 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-nursingexams/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: Environmental Resource Management Cognitive 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. King B. Henderson C. Roy D. 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-nursingReference 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 Development Cognitive 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. Henderson Henderson B. Orem C. Swanson D. 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-nursingReference: 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: Safe and quality nursing care Cognitive 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. Neuman B. Johnson C. Watson D. 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. Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentalsof-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursingtest-i-history-concepts-and-theories Nursing Process: Assessment 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 possible A. Henderson Henderson B. Abdellah C. Levin D. 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-nursingReference 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 Development 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. Benner Benner B. Watson C. Leininger D. 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. Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursingReference: 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 Development Cognitive Domain: Knowledge 18. Caring involves 5 processes, KNOWING, BEING WITH, DOING FOR, ENABLING and MAINTAINING BELIEB. A. Benner Benner B. Watson C. Leininger D. Swanson

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-nursingReference 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 Development Affective 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. A. Benner Benner B. Watson

C. Leininger D. Swanson

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-nursingReference 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 Development Affective 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. Benner B. Watson C. Leininger D. 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. Reference:http://www.rnpedia.com/home/exams/fundamentals-of-nursing-exams/fundamentalsof-nursing-test-i-history-concepts-and-theories/answer-and-rationale--fundamentals-of-nursingtest-i-history-concepts-and-theories Nursing Process: Assessment Core Competency: Personal and Professional Development 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 value b. An acceptance of the treatment c. The client is agreeable to the required procedure d. 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: Assessment

Core Competency: Communication Cognitive 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 slowly b. Stand close to the client and speak slowly c. Arrange for an interpreter when communicating with the client d. 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 (5 th ed., pp71-72) Lewis, S., Heitkernper, M., Dirksen, S., & Bucher, L. (2007) Medical Surgical nursing: assessment and management of clinical problesm (7 th ed.,p36)

Nursing Process: Intervention Core Competency: Collaboration adn teamwork Cognitive Domain: Application 23. Which of the following meal meal trays would be appropriate appropriate for a nurse to deliver deliver to a client client of orthodox Judaism faith who follows a kosher diet a. Pork roast, rice, vegetables, vegetables, mixed fruit, milk b. Crab salad on a croissant, vegetables with dip, potato salad, milk c. Sweet and sour chicken with rice and vegetables, mixed fruit, juice d. 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: Intervention Core Competency: Ethico moral responsibility Cognitive Domain: Analysis 24. When counseling a female arnish client, a nurse should: a. Speak only to the husband b. Use complex medical terminology c. Avoid using scientific or medical jargon d. 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 (4 th 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 spicy b. Primarily eats raw fish c. Enjoys eating red meat such as steaks d. 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 Anthropology (p78) Nursing Process: Assessment Assessment Core Competency: Ethico moral responsibility Cognitive Domain: Analysis 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 (7 th ed., p424) Nursing Process: Intervention Core Competency: Ethico moral responsibility Cognitive Domain: Analysis 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 salad b. Chicken noodle soup c. Steak with baked potato

d. 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 (7 th ed., p1096) Nursing Process: Intervention Core Competency: Management of resources and environment Cognitive 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 back b. Vigorously massage bony prominences. c. Position hands 2 to 4 inches from the body d. 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 collaborative care (6 th ed., pp.12-13) Nursing Process: Intervention Core Competency: Safe and Quality nursing care Cognitive 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 analgesic b. Offer an analgesic pain c. Check the client’s vital signs d. 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: Assessment Assessment Core Competency: Quality improvement Cognitive 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 insomia b. Ginger is used to improved memory c. Echinacea is used for erectile d. 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 nursing:Clinic al management for th positive outcomes (8 ed.., p. 1797) Nursing Process: Evaluation Core Competency: Collaboration and teamwork Cognitive Domain: Comprehension

31. These are roles and functions of the nurse, EXCEPT: A. Caregiver B. Communicator C. Teachers D. Lawyer ANSWER: D RATIONALE: 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 8 th EDITION, Kozier & ERB’S CORE COMPETENCY: TAXONOMY: NURSING PROCESS:

32. Which of the following is an example of continuing education for nurses? a. Attendin a. Attending g the hospital’s hospital’s orientation orientation program program b. Talking with a company representative about a new piece of equipment c. Completing a workshop on ethical aspects of nursing d. Obtaining information about the facility’s new computer charting system. ANSWER: C RATIONALE: 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 Environment TAXONOMY: CD – Analysis

NURSING 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 Tubman b. Florence Nightingale c. Fabiola d. Dorothea Dix e. Sojourner Truth ANSWER: B & C RATIONALE: Florence Nightinale, contributed to the nursing care of soldiers in the Crimean war. C – C – Fabiola, used her wealth to provide houses of caring and healing during the Roman Empira. REFERENCE: Fundamentals of nursing 8 th EDITION, Kozier Kozier & ERB’S CORE COMPETENCY: TAXONOMY: CD - Knowledge NURSING PROCESS: Not Applicable

34. Which of the following activities best represents health promotion? a. Administering immunizations b. Giving a bath c. Preventing accidents in the home d. Performing diagnostic procedures ANSWER: C RATIONALE: Health Promotion focuses on maintaining normal status without consideration of diseases. A – 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 8 th EDITION, Kozier & ERB’S CORE COMPETENCY: TAXONOMY: CD – Knowledge NURSING PROCESS: Not Applicable 35. Who are America’s first two trained nurses? a. Barton and wald b. Dock and sanger c. Richards and Mahoney d. Henderson and Breckinridge ANSWER: C RATIONALE: Linda Richards was America’s first trained nurse, and Mary Mahoney was America’s first trained nurse. nurse. REFERENCE: Fundamentals of nursing 8 th EDITION, Kozier & ERB’S CORE COMPETENCY: TAXONOMY: CD – Knowledge NURSING 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 beginner b. Competent c. Proficient d. Expert ANSWER: B RATIUONALE: the competent 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands. A – 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 8 th EDITION, Kozier & ERB’S CORECOMPETENCY: Not Applicable TAXONOMY: CD – Knowledge NURSING PROCESS: Not Applicable

37. Which professional organization developed a code for nursing students? a. ANA b. NLN c. AACN d. NSNA ANSWER: D RATIONALE: the National Student Nurses’ Association developed the Code Of Academic and Clinical Conduct for nursing students in 2001. A – A – ANA, developed Standards of Nursing Practices. B – NLN, focuses on nursing education C – 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 8 th EDITION, Kozier & ERB’S CORE COMPETENCY: Record management TAXONOMY: CD – Knowledge NURSING PROCESS: Not applicable

38. Which of the following social forces is most likely to significantly impact the future supply and demand for nurses? a. Aging b. Economics c. Science/technology d. 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 8 th EDITION, Kozier & ERB’S CORE COMPETENCY: Quality Improvement TAXONOMY: 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 harmed b. Right to full disclosure c. Right of privacy and confidentiality d. Right of self – – determination ANSWER: D RATIONALE: the right of self – 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 8 th EDITION, Kozier & ERB’S CORE COMPETENCY: Safe, Effective Care Environment TAXONOMY: CD – Comprehension NURSING PROCESS: Diagnosis

40. Order: To infuse Esmolol Hcl 5g in 500 ml D5W. Titrate 50 –100 –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 D5W Titrate 50 – 50 –100 100 mcg/kg/min Systolic blood pressure at 120mm hg A. Equivalent: Equivalent: 5g = 500 500 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.


Nursing Process: Assessing

Core Competency: Safe and quality of nursing Cognitive Domain: Application

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 system atically 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.


Nursing Process: Assessing Core Competency: Safe and quality of nursing Cognitive Domain: Application 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


Nursing Process: Assessing Core Competency: Safe and quality of nursing Cognitive Domain: Application 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— depression —a later stage of grieb.



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.



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.


Nursing Process: Assessing Core Competency: Safe and quality of nursing Cognitive Domain: Application 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. fin a. 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 may result from from feeling of of helplessness, helplessness, isolation, isolation, or insecurity. insecurity. This response response helps 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 anxiety- inducing situation. Because the other options ignore the patient’s feeli ng and block communication, they would not reduce anxiety.


Nursing Process: Assessing Core Competency: Safe and quality of nursing Cognitive Domain: Application 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.


Nursing Process: Assessing

Core Competency: Safe and quality of nursing Cognitive Domain: Application

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.



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 turgor turgor B. Hydration C. Organs D. 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 practice Nursing Process: Evaluation Cognitive 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. 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 90-degree angle angle can be used when when giving a subcutaneous subcutaneous injection injection Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 705-709 Core Competency Standard: Quality improvement Nursing Process: Implementation Cognitive 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 establish a baseline B. Once per year C. Every 2 years D. 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 Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 500-515 Core Competency Standard: Safe & quality nursing practice Nursing Process: Implementation Cognitive 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 see a newly newly admitted client. B. ambulating the client in the hallway. C. administering administering pain pain medication D. placing wrist restraints restraint s 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 & environment Nursing Process: Implementation Cognitive Domain: Application

55. Which element in the circular chain of infection can be eliminated by preserving skin integrity? A. Host B. Reservoir C. Mode of transmission transmiss ion D. Portal of entry Rationale: In the circular chain 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. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 330-350 Core Competency Standard: Research Nursing Process: Diagnosis Cognitive 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 environment B. Turning on the patient’s room ventilator C. Opening the door of the patient’s room leading into the hospital corridor D. 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. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 2005-2010 Core Competency Standard: Safe & quality nursing practice Nursing Process: Implementation Cognitive Domain: Application

57. Which of the following patients is at greater risk for contracting an infection? A. A patient patient with leukopenia leukopenia

B. A patient receiving broad-spectr broad-spectrum um antibiotics C. A postoperative patient who has undergone orthopedic surgery D. 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. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 1029-1084 Core Competency Standard: Research Nursing Process: Evaluation Cognitive Domain: Knowledge

58. Effective hand washing requires the use of: A. Soap or detergent detergent to promote promote emulsification emulsification B. Hot water to destroy bacteria C. A disinfectant to increase surface tension D. 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. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 1033-1049 Core Competency Standard: Safe & quality nursing practice Nursing Process: Implementation Cognitive Domain: Application 59. After routine patient contact, hand washing should last at least: A. 30 seconds seconds B. 1 minute C. 2 minute D. 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. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 804-812 Core Competency Standard: Quality improvement Nursing Process: Implementation Cognitive Domain: Knowledge

60. Which of the following procedures always requires surgical asepsis? A. Vaginal instillation instillation of of conjugated conjugated estrogen estrogen B. Urinary catheterization C. Nasogastric tube insertion D. 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. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 658-660 Core Competency Standard: Safe & quality nursing practice Nursing Process: Implementation Cognitive Domain: Application

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 rather than sterile gloves, gloves, to handle handle a sterile sterile item B. Touching the outside wrapper of of sterilized material without sterile gloves C. Placing a sterile object on the edge of the sterile field D. 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, 1020-1023 Core Competency Standard: Safe & quality nursing practice Nursing Process: Implementation Cognitive Domain: Application

62. All of the following statement are true about donning sterile gloves except: A. The first glove glove should be picked up by grasping grasping the the inside of 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 wrist D. The inside of the glove is considered sterile Rationale: The inside of the glove is always considered to be clean, but not sterile. Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 1033-1049

Core Competency Standard: Safe & quality nursing practice Nursing Process: Implementation Cognitive Domain: Application

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) b) c) d)

Sitting upright Side-lying Supine Prone

RATIONALE: A. a client client in status asthmaticus asthmaticus should should be placed placed in the position position that that promotes promotes air exchanga. Sitting upright eases the motion of the diaphragm and promotes air exchange. NURSING PROCESS: intervention CORE COMPETENCY: Safe and Quality nursing care COGNITIVE DOMAIN: analysis 64. A client undergoes an open reduction and internal fixation to treat a fractured right hip. Five hours after surgery, after surgery, the nurse should maintain the client’s affected leg in which position? a) b) c) d)

External rotation Abduction Flexion 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: intervention CORE COMPETENCY: legal responsibility COGNITIVE DOMAIN: application A pregnant pregnant client is in in the first first stage of of labor. The nurse should should include which which of the following in the client’s plan of care during this stage? a) Encourage the client to lie on her left side b) Instruct the client to ambulate c) Urge the client to accept pain medication d) 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: planning CORE COMPETENCY: Safe and Quality nursing care COGNITIVE 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) b) c) d)

Side-lying Supine Knee-chest Lithotomy

RATIONALE: A. side lying lying position help prevent prevent aspiration. aspiration. The other options options don’t don’t provide this advantage. NURSING PROCESS: intervention CORE COMPETENCY: personal and professional development COGNITIVE DOMAIN: comprehension 66. Which assessment finding would indicate that a client’s abdominal ascites are decreasing? a) b) c) d)

The amount of ankle ankle edema remains the same Abdominal skin becomes shinier Urine output per void increases 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: assessment CORE COMPETENCY: health education COGNITIVE 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 class b) Assessing the strengths and needs of the community while identifying barriers to learning c) Choosing a health promotion or health belief model as a framework d) 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 learning NURSING PROCESS: planning CORE COMPETENCY: Safe and Quality nursing care COGNITIVE DOMAIN: analysis 68. Although a client’s physiologic physiologic response response to a health health crisis is important important to the the health outcome, which of the following nursing interventions also must be addressed? a) Teach the family how to care for the client b) Help the client effectively cope with the crisis c) Maintain I.V access, medications and diet

d) 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 emoti onal, spiritual and psychological aspects of his crisis, the other components of care may be ineffective as well NURSING PROCESS: intervention CORE COMPETENCY: ethico-moral ethico-moral responsibility responsibility COGNITIVE DOMAIN: application 69. Nursing management of a client with a pulmonary embolism focuses on which of the following actions? a) b) c) d)

Assessing oxygenation status Monitoring the oxygen delivery device Monitoring for other sources of clots Determining whether the client requires another ventilation-perfusion ventilation -perfusion scan

RATIONALE: A. pulmonary pulmonary embolism focuses on on assessing assessing oxygenation oxygenation status status and ensuring ensuring treatment is adequata. Option B, C and D are other nursing responsibilities, but they aren’t the focus care NURSING PROCESS: intervention CORE COMPETENCY: quality improvement COGNITIVE 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) b) c) d)

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

RATIONALE: A. a foul odor odor from a cast may be a sign of infection. infection. The nurse nurse needs needs to assess 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 paresthesia NURSING PROCESS: assessment CORE COMPETENCY: Safe and Quality nursing care COGNITIVE DOMAIN: analysis 71. Which of the following chronic complications is associated with diabetes mellitus? a) b) c) d)

Dizziness, dyspnea on exertion and angina Retinopathy, neuropathy and coronary artery disease (CAD) Leg ulcers, cerebral ischemic event and pulmonary infarcts 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: analysis CORE COMPETENCY: health education COGNITIVE DOMAIN: knowledge

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

Have the client perform all basic care without help Tell the client morning care must be done by 9 am Give the client a written list of activities he’s expected to do 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: intervention CORE COMPETENCY: Safe and Quality nursing care COGNITIVE 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 preference d. Client complaints of any chest pain, dyspnea, or abdominal pain. Answer:d Rationale: 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. S eries. 5rd edition copyright 2006 by Lippincott Williams & Wilkins. Nursing Process: assessment Cognitive Domain: knowledge Core 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 answ er‖may car‖ or any similarly disingenuous reply.

Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins. Nursing Process: Assessment Cognitive Domain: Comprehension Core competency: record management 75. For which of the following time periods would the nurse notify the physician that the client had no bowel sounds? a. 2 minutes b. 3 minutes c. 4 minutes d. 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; Implementation Cognitive Domain: Knowledge Core competency: Health education 76. Which of the following area is the best area for auscultating the apical pulse? a. Aortic arch b. Pulmonic area c. Tricuspid Tricuspi d area d. Mitral area Answer: d Rationale: 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: assessment Cognitive Domain: Knowledge Core competency: Health education 77. 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 between the ages of 35 and 45. b. The ―tail of Spence‖ area must be included in self -examination. self -examination. c. The position of choice for the breast breast examination is supine. d. A pad should be placed under the opposite scapula of the breast 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: assessment Cognitive 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 otoscope inferiorly into the distal portion of the external canal c. Inserting the otoscope otoscope superiorly into the proximal two thirds of the external canal. d. Bracing the examiner’s hand against the client’s head. Answer: c Rationale: 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 Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins. Nursing Process: Assessment Cognitive Domain: Knowledge Core 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 test c. Assessing for the Homan’s Homan’s sign d. Palpating the pedal pulses Answer: d Rationale:Palpating the client’s pedal pulses assist in determining is arte rial blood suppy to the lower extremities id sufficient. Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins. Nursing Process Assessment Cognitive Domain: knowledge Core competency: safe and quality nursing care 80. Which of the following examinations requires the nurse to wear gloves? a. Oral b. Ophthalmic c. Breast d. Integumentary Answer: a Rationale: 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: assessment Cognitive Domain: knowledge Core competency: health education 81. 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: Assessment Cognitive Domain: Implementation Core competency: safely and quality nursing care 82. 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. Tympany b. Resonance c. Dullness d. Hyper resonance Answer: b Rationale: 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: Assessment Cognitive Domain: Knowledge Core 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 test b. Weber’s test c. Watch tick test d. 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 dressin c. Which observation of the wounds warrants immediate physician notification? a. Approximated wound edges b. Yellow purulent drainage c. Sutures in place d. 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.

Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN Nursing Process: Assessment 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 hypotension b. It can cause hypersensitivity hypersensitivit y 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: Evaluation Core Competency Standard: Safe and quality nursing care Cognitive Domain 86. To evaluate a client’s posterior pulse, where should the nurse palpate? a. Medially in the antecubital space b. Midway between the superior iliac spine and symphysis pubis c. On the inner aspect of the ankle, below the medial malleolus d. 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: Evaluation Core Competency Standard: Safe and quality nursing care Cognitive Domain 87. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a. Impaired gas exchange b. Impaired oral mucous membranes c. Imbalanced nutrition: Less than body requirements d. 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. Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN Nursing Process: Diagnosis Core Competency Standard: Safe and quality nursing care

Cognitive 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 feet b. Petechiae c. Leg ulcers d. 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/ Diagnosis Core Competency Standard: Safe and quality nursing care Cognitive 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 relationship c. Be flexible regarding rules d. Show support while controlling controllin g 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 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 care Cognitive Domain/Application Domain/Application 90. 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 care Cognitive Domain/Application Domain/Application

91. 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 cardiopulmonar y resuscitation(CPR) resuscitat ion(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: Implementation Core Competency Standard: Safe and quality nursing care Cognitive Domain/Analysis 92. Which moral principle is the nurse applying by deciding what is best for a client and acting without consulting the individual? a. Beneficence b. Paternalism c. Fidelity d. 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: Implementation Core Competency Standard: Safe and quality nursing care Cognitive Domain/Comprehension

Fundamentals of Nursing (Group 1)-- 92 Question

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