Fundamentals of Nursing Part 1

FUNDAMENTALS OF NURSING PART PART 1

1.

Using Using the princ principl iples es of standar standard d precauti precautions ons,, the nurse nurse would wear gloves in what nursing interventions? a. Prov Provid idin ing g a back back mass massag agee  b. Feeding a client client c. Prov Provid idin ing g hai hairr car caree d. Prov Provid idin ing g ora orall hyg hygie iene ne 2. he nurse nurse is is prepar preparing ing to take take vita vitall sign in an aler alertt client client admitted to the hospital with dehydration secondary to vomiting and diarrhea. !hat is the best method used to assess the client"s temperature? a. #ral  b. $%illary c. &adial d. 'eat 'eat sen sensi siti tive ve tap tapee (. $ nurse nurse obtained obtained a client" client"ss pulse pulse and and found found the rate to be above normal. he nurse document this findings as) a. achypnea  b. 'yper pyre%ia c. $rrythmia d. achy chycard cardiia *. !hich !hich of the follo followi wing ng action actionss should should the nurse nurse take take to use a wide base support when assisting a client to get up in a chair? a. +end +end at the the waist waist and and place place arms arms unde underr the client"s arms and lift  b. Face the client, bend knees and place hands on client"s forearm and lift c. pre pread ad his his or or her her feet feet apar apartt d. ight ighten en his his or her her pelv pelvic ic musc muscles les -. $ clien clientt had had oral oral surge surgery ry follo followi wing ng a moto motorr vehi vehicl clee accident. he nurse assessing the client finds the skin flushed and warm. !hich of the following would be the  best method to take the client"s client"s body body temperature? temperature? a. #ral  b. $%illary c. $rter terial ial lin line d. &ectal . $ clien clientt who is uncons unconscio cious us needs needs fre/ue fre/uent nt mouth mouth care. care. !hen performing a mouth care, the best position of a client is) a. Fowl Fowler er"s "s posi positi tion on  b. ide lying c. upine d. rende ndelenb lenbur urg g 0. $ clien clientt is hospita hospitali lied ed for the the first first time, time, which which of the following actions ensure the safety of the client? a. eep eep unnece unnecessa ssary ry furn furnitu iture re out out of the way way  b. eep the lights lights on at all time time c. eep eep sid sidee rail railss up at all all tim timee d. eep eep all all e/uipm e/uipment ent out of view view 3. $ walk4 walk4in in clien clientt ente enters rs into into the the clin clinic ic with with a chie chief  f  complaint complaint of abdominal abdominal pain and diarrhea. diarrhea. he nurse takes takes the client"s client"s vital vital sign hereafter. hereafter. !hat phrase of  nursing process is being implemented here by the nurse? a. $ssessment  b. 5iagnosis c. Planning d. 6mpl 6mplem emen enta tati tion on 7. 6t is best best desc descri ribe be as a syst system emat atic ic,, rati ration onal al metho method d of   planning and providing nursing care for individual, families, group and community a. $ssessment  b. 8ursing Process Process c. 5iagnosis d. 6mpl 6mplem emen enta tati tion on 19. :%change :%change of gases gases takes place place in which of the followi following ng organ? a. idney  b. ;ungs c. ;iver d. 'eart 11. he
c. ;eft eft ve ventri ntricl clee d. &igh &ightt vent ventri ricl clee 12. $ muscula muscularr enlarge enlarge pouch or sac that lies lies slightly slightly to the left which is used for temporary storage of food= a. >allbladder  b. Urinary bladder c. tomach d. ;ungs 1(. he ability ability of the body to defend defend itself itself against against scientific scientific invading agent such as baceria, to%in, viruses and foreign  body a. 'ormones  b. ecretion c. 6mmunity d. >lands 1*. 'ormones 'ormones secrete secreted d by 6slets 6slets of ;angerhan ;angerhanss a. Prog Progeester steron onee  b. estosterone estosterone c. 6nsulin d. 'emogl oglobin 1-. 6t is a transparent transparent membran membranee that focuses focuses the light light that enters the eyes to the retina. a. ;ens  b. clera c. tt.  b. >tts. c. 5p. d. 5r. 2*. he abbrevi abbreviation ation for for micro micro drop is= is= a. Bgtt  b. gtt c. mdr d. mgts 2-. !hich !hich of the following following is is the meaning meaning of P&8? P&8? a. !hen ad advice

 b. 6mmediately c. !hen necessary d. 8ow 2. !hich of the following is the appropriate meaning of  <+&? a.
(7.

*9.

*1.

*2.

*(.

**.

*-.

*.

*0.

*3.

*7.

-9.

a. o promote hand circulation  b. o prevent the transfer of microorganism c. o avoid touching the client with a dirty hand d. o provide comfort !hat should be done in order to prevent contaminating of the environment in bed making? a. $void funning soiled linens  b. trip all linens at the same time c. Finished both sides at the time d. :mbrace soiled linen he most important purpose of cleansing bed bath is) a. o cleanse, refresh and give comfort to the client who must remain in bed  b. o e%pose the necessary parts of the body c. o develop skills in bed bath d. o check the body temperature of the client in  bed !hich of the following techni/ue involves the sense of  sight? a. 6nspection  b. Palpation c. Percussion d. $uscultation he first techni/ues used e%amining the abdomen of a client is) a. Palpation  b. $uscultation c. Percussion d. 6nspection $ techni/ue in physical e%amination that is use to assess the movement of air through the tracheobronchial tree) a. Palpation  b. $uscultation c. 6nspection d. Percussion $n instrument used for auscultation is) a. Percussion4hammer  b. $udiometer c. tethoscope d. phygmomanometer &esonance is best describe as) a. ounds created by air filled lungs  b. hort, high pitch and thudding c. oderately loud with musical /uality d. 5rum4like he best position for e%amining the rectum is) a. Prone  b. im"s c. nee4chest d. ;ithotomy 6t refers to the manner of walking a. >ait  b. &ange of motion c. Fle%ion and e%tension d. 'opping he nurse asked the client to read the nellen chart. !hich of the following is tested) a. #ptic  b. #lfactory c. #culomotor d. roclear $nother name for knee4chest position is) a. >enu4dorsal  b. >enu4pectoral c. ;ithotomy d. im"s he nurse prepare 6 inCection 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. $pply ice on the inCection site c. $dminister at a *-D angle d. Use the E4track techni/ue

FUNDAMENTALS OF NURSING PART 2

1.

2.

(.

*.

-.

.

0.

3.

7.

he most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be= a. aintain the patient on strict bed rest at all times  b. aintain the patient in an orthopneic position as needed c. $dminister o%ygen by enturi mask at 2*G, as needed d. $llow a 1 hour rest period between activities he nurse observes that r. $dams begins to have increased difficulty breathing. he elevates the head of  the bed to the high Fowler position, which decreases his respiratory distress. he nurse documents this breathing as) a. achypnea  b. :upnca c. #rthopnea d. 'yperventilation he physician orders a platelet count to be performed on rs. mith after breakfast. he nurse is responsible for) a. 6nstructing the patient about this diagnostic test  b. !riting the order for this test c. >iving the patient breakfast d. $ll of the above rs. itchell has been given a copy of her diet. he nurse discusses the foods allowed on a -994mg low sodium diet. hese include) a. $ ham and wiss cheese sandwich on whole wheat bread  b. ashed potatoes and broiled chicken c. $ tossed salad with oil and vinegar and olives d.
19. !hich of the following principles of primary nursing has  proven the most satisfying to the patient and nurse? a. 6 tract? a. uaiac test c. ital signs d. $bdominal girth 10. he correct se/uence for assessing the abdomen is) a. ympanic percussion, measurement of  abdominal girth, and inspection  b. $ssessment for distention, tenderness, and discoloration around the umbilicus. c. Percussions, palpation, and auscultation d. $uscultation, percussion, and palpation 13. 'igh4pitched gurgles head over the right lower /uadrant are)

a. $ sign of increased bowel motility  b. $ sign of decreased bowel motility c. 8ormal bowel sounds d. $ sign of abdominal cramping 17. $ patient about to undergo abdominal inspection is best  placed in which of the following positions? a. Prone  b. rendelenburg c. upine d. ide4lying 29. For a rectal e%amination, the patient can be directed to assume which of the following positions? a. >enupecterol  b. ims c. 'oriontal recumbent d. $ll of the above 21. 5uring a &omberg test, the nurse asks the patient to assume which position? a. itting  b. tanding c. >enupectoral d. rendelenburg 22. 6f a patient"s blood pressure is 1-9J7, his pulse pressure is) a. -*  b. 7 c. 1-9 d. 2* 2(. $ patient is kept off food and fluids for 19 hours before surgery. 'is oral temperature at 3 a.m. is 77.3 F @(0.0
(9. he physician orders the administration of high4humidity o%ygen by face mask and placement of the patient in a high Fowler"s position. $fter assessing rs. Paul, the nurse writes the following nursing diagnosis) 6mpaired gas e%change related to increased secretions. !hich of  the following nursing interventions has the greatest  potential for improving this situation? a. :ncourage the patient to increase her fluid intake to 299 ml every 2 hours  b. Place a humidifier in the patient"s room. c.
a. 6nfancy  b. Moung adulthood c. ray develops hypokalemia. !hich of the following is the most significant symptom of his disorder? a. ;ethargy  b. 6ncreased pulse rate and blood pressure c. uscle weakness d. uscle irritability *1. !hich of the following nursing interventions promotes  patient safety? a. $sses the patient"s ability to ambulate and transfer from a bed to a chair  b. 5emonstrate the signal system to the patient c. erhig"s diseaseA d. $lheimer"s disease *3. he nurse"s most important legal responsibility after a  patient"s death in a hospital is) a. #btaining a consent of an autopsy  b. 8otifying the coroner or medical e%aminer c. ;abeling the corpse appropriately d. :nsuring that the attending physician issues the death certification *7. +efore rigor mortis occurs, the nurse is responsible for) a. Providing a complete bath and dressing change

 b.

Placing one pillow under the body"s head and shoulders c. &emoving the body"s clothing and wrapping the  body in a shroud d. $llowing the body to rela% normally -9. !hen a patient in the terminal stages of lung cancer   begins to e%hibit loss of consciousness, a maCor nursing  priority is to) a. Protect the patient from inCury  b. 6nsert an airway c. :levate the head of the bed d. !ithdraw all pain medications

FUNDAMENTALS OF NURSING PART 3

1

2

(

*

-



0

3

7

!hich element in the circular chain of infection can be eliminated by preserving skin integrity? a 'ost  b &eservoir c ode of transmission d Portal of entry !hich of the following will probably result in a break in sterile techni/ue for respiratory isolation? a #pening the patient"s window to the outside environment  b urning on the patient"s room ventilator c #pening the door of the patient"s room leading into the hospital corridor d Failing to wear gloves when administering a  bed bath !hich of the following patients is at greater risk for  contracting an infection? a $ patient with leukopenia  b $ patient receiving broad4spectrum antibiotics c $ postoperative patient who has undergone orthopedic surgery d $ newly diagnosed diabetic patient :ffective hand washing re/uires the use of) a oap or detergent to promote emulsification  b 'ot water to destroy bacteria c $ disinfectant to increase surface tension d $ll of the above $fter routine patient contact, hand washing should last at least) a (9 seconds  b 1 minute c 2 minute d ( minutes !hich of the following procedures always re/uires surgical asepsis? a aginal instillation of conCugated estrogen  b Urinary catheteriation c  8asogastric tube insertion d
19

11

12

1(

1*

1-

1

10

13

17

d &apid eye movements $ll of the following statement are true about donning sterile gloves e%cept) a he first glove should be picked up by grasping the inside of the cuff.  b he second glove should be picked up by inserting the gloved fingers under the cuff  outside the glove. c he gloves should be adCusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist d he inside of the glove is considered sterile !hen removing a contaminated gown, the nurse should  be careful that the first thing she touches is the) a !aist tie and neck tie at the back of the gown  b !aist tie in front of the gown c
29 $ patient with no known allergies is to receive penicillin every  hours. !hen administering the medication, the nurse observes a fine rash on the patient"s skin. he most appropriate nursing action would be to) a !ithhold the moderation and notify the  physician  b $dminister the medication and notify the  physician c $dminister the medication with an antihistamine d $pply corn starch soaks to the rash 21 $ll of the following nursing interventions are correct when using the E4track method of drug inCection e%cept) a Prepare the inCection site with alcohol  b Use a needle that"s a least 1L long c $spirate for blood before inCection d &ub the site vigorously after the inCection to  promote absorption 22 he correct method for determining the vastus lateralis site for 6.. inCection is to) a ;ocate the upper aspect of the upper outer  /uadrant of the buttock about - to 3 cm below the iliac crest  b Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm c Palpate a 1L circular area anterior to the umbilicus d 5ivide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh 2( he mid4deltoid inCection site is seldom used for 6.. inCections because it) a , 1 L long  b 22>, 1L long c 22>, 1 L long d 2->, -J3L long 2- he appropriate needle gauge for intradermal inCection is) a 29>  b 22> c 2-> d 2> 2 Parenteral penicillin can be administered as an) a 6 inCection or an 6 solution  b 6 or an intradermal inCection c 6ntradermal or subcutaneous inCection d 6 or a subcutaneous inCection 20 he physician orders gr 19 of aspirin for a patient. he e/uivalent dose in milligrams is) a 9. mg  b 19 mg c 9 mg d 99 mg 23 he physician orders an 6 solution of de%trose -G in water at 199mlJhour. !hat would the flow rate be if the drop factor is 1- gtt Q 1 ml? a - gttJminute  b 1( gttJminute c 2- gttJminute d -9 gttJminute 27 !hich of the following is a sign or symptom of a hemolytic reaction to blood transfusion? a 'emoglobinuria  b
(1

(2

((

(*

(-

(

(0

(3

(7

*9

 b raduated from an associate degree program and is a registered professional nurse d 6 bleeding  b 6mpending constipation c $n effect of medication

*1

*2

*(

**

*-

*

*0

*3

*7

d +ile obstruction 6n which step of the nursing process would the nurse ask  a patient if the medication she administered relieved his  pain? a $ssessment  b $nalysis c Planning d :valuation $ll of the following are good sources of vitamin $ e%cept) a !hite potatoes  b