TEST I
HAND WASHING Situa Situatio tion: n:
Initia Initiatio tion n of pract practice ices s to preve prevent nt the the transm transmiss ission ion of of microo microorg rgani anisms sms is gen genera erally lly a nursi nursing ng responsibility responsibility and is based on a comprehensive comprehensive assessment of the client.
1.
When you are performing surgical hand hygiene, hygiene, you must keep hands _____ a. Above elbows c. At a 45 degree angle b. !elow elbows d. "n a comfortable position
#.
$ou are provi providin ding g an educ educati ational onal sessio session n to a group group of of young young people people.. $ou $ou prepa prepare re an an instr instruct uction ion list list for for them them regarding the correct procedure for medical hand hygiene. hygiene. Which instructions do you include on the list% a. &urn &urn on the water water.. Allow Allow the warm warm wate waterr to to wet wet the the hand hands. s. Apply Apply soap soap to the the hand hands s and and rub rub them them vigorously. 'eep hands pointed upward. (inse the hands. )ry the hands using a paper towel. &urn the water faucet off with the paper towel. b. &urn &urn on the water water.. Allow Allow the warm warm wate waterr to to wet wet the the hand hands. s. Apply Apply soap soap to the the hand hands s and and rub rub them them vigorously. 'eep hands pointed downward. (inse the hands. )ry the hands using a paper towel. &urn the water faucet off with the paper towel. c. &urn &urn on the water water.. Allow Allow the warm warm wate waterr to to wet wet the the hand hands. s. Apply Apply soap soap to the the hand hands s and and rub rub them them vigorously. 'eep hands pointed upward. (inse the hands. )ry the hands using a paper towel. &urn the water off with the clean hands. d. &urn &urn on the water water.. Allow Allow the warm warm wate waterr to to wet wet the the hand hands. s. Apply Apply soap soap to the the hand hands s and and rub rub them them vigorously. 'eep hands pointed downward. (inse the hands. )ry the hands using a paper towel. &urn the water off with the clean hands.
*.
What is the most important important aspect of hand hygiene% a. &ime b. +oap
c.
-lace ace the following -- in order of donning _____ _____ a. /loves, eye protection, mask, and gown b. 0ask, gloves, es, gown, and eye eye pro protection d.
c. /own, mask, eye protection, and gloves ye protection, gloves, es, mask, and gown
At which time should you remove--% remove--% a. "nside clients room b. 2utside clients room
c. d.
4.
5.
Water
d.
riction
At doorway 2utside clients room or at doorway
COLOSTOMY Situa Situatio tion: n:
A clien clientt has has a colo colosto stomy my beca because use of of colo colon n cance cancer. r. You You are are teach teachin ing g him him colo colosto stomy my care. care.
1.
&o review, you ask him, “When should you empty the colostomy bag?” $ou $ou know your teaching is effective when effective when hestates _____ a. “Every time I see stool in the bag I should empty it.” b. “I should empty the bag at least three times a day.” c. “I should empty the bag when it’s about one – third or one – half full.” d. “I’ll let my wife empty it. he d oesn’t mind.”
#.
"t is is imp impor orta tant nt for for you you to to tea teach ch him him to care care for for the the skin skin aro aroun und d the the stom stoma a by ____ _____ _ a. Avoi Avoidi ding ng the the use use of soap soap and and ot other her irr irrit itat atin ing g age agent nts s b. (ins (insin ing g wit with h hyd hydro roge gen n per pero3 o3id ide e and and appl applyi ying ng a gau gaue e pad pad c. -our -ourin ing g sal salin ine e ove overr the the stom stoma a and and wipi wiping ng awa away y the the feca fecall mat matte ter r d. Washi Washing ng the the area area gent gently ly with with soap soap and and wate waterr bef befor ore e appl applyi ying ng an an appl applia ianc nce e
*.
$ou also also teach teach him how to appl apply y the the colos colostom tomy y bag. bag. ow ow much much skin skin shoul should d remai remain n e3pos e3posed ed betw between een the the stom stoma a and the ring of the bag% a. 2ne eight inch c. 2ne half inch b. 2ne fourth inch d. 2ne inch
4.
e asks you, “Will I ever be able to swim again?” $our $our best response response would be _____ a. “!es" you should be able to swim again" even with the colostomy.” b. “!ou should avoid immersing the colostomy in water.” c. “#o" you should avoid getting the colostomy wet.” d. “$on’t worry about that. !ou will be able to live %ust li&e you did before.”
5.
$ou kn know yo your di dietary te teaching is is effective when effective when hestates, “It is important that I eat _____ eat _____ 1
a. b. c. d. F O ! S:
'ood low in fiber so that there is less stool.” (land foods so that my intestines do not becomeirritated.” Everything I ate before the operation andavoiding foods that cause gas and foul – odor.” oft foods that are more easily digested and absorbedby my large intestine.” "ischarge instructions for a client #ho has been operated on for colorectal cancer include irrigating the colostomy.
1.
When do you plan to teach him to irrigate a colostomy% a. &he stool starts to become formed b. e can lie on the side comfortably c. &he abdominal incision is closed and contamination is no longer a danger d. &he perineal wound heals and he can sit comfortably on the commode
#.
When preparing to teach him to irrigate a colostomy, you should plan to perform the procedure _____ a. +everal hours before visitors b. -rior to eating food in the morning c. After he accepts the alteration in body image d. When he would usually have had a bowel movement
*.
When observing a return demonstration of a colostomy irrigation, you know that further teaching is re6uired if he _____ a. 7lamps off the flow of fluid when feeling uncomfortable b. 8ubricates the tip of the catheter prior to inserting it into the stoma c. )iscontinues the insertion of fluid after only 599 m8 of fluid has been instilled d. angs the irrigation bag on the bathroom door clothes hook during fluid insertion
4.
$ou know your teaching is effective when he states hell contact the physician if _____ a. e notices a loss of sensation to touch in the stoma b. e has difficulty inserting the irrigation tube into the stoma c. e e3periences abdominal cramping while the irrigant is infusing d. e e3pels flatus while the return is running out
5.
When comparing the procedures of a colostomy irrigation and an enema, you understand an intervention that is uni6ue to a colostomy irrigation is _____ a. -ositioning the client for evacuation of the bowel b. 8ubricating the catheter tip with a water soluble :elly c. ;sing a cone shaped tip for the end of the instillation catheter d. 7learing the tubing of air before insertion of the irrigating solution
THERAPEUTIC DIETS Situation:
You are brushing up on the most commonly as$ed therapeutic diets in the %&E.
1.
$ou are aware that a client can be placed on a clear li6uid diet for a ma)imum of how many days% a. 1 b. # c. * d. 4
#.
A client is placed on a low residue diet before bowel surgery. $ou teach him that it is necessary to _____ a. 8ower the bacterial count in the /" tract c. -revent irritation of the intestinal mucosa b. 8imit production of flatus in the intestine d. (educe the amount of stool in the large bowel
*.
What is the best snack for a client re6uiring increased potassium% a. -ear b. Apple c. 2range
d.
!anana
A vegan is at ris& for which nutritional deficiency% a.
d.
4.
5.
#.
*.
)iet therapy for urinary calculi of calcium phosphate would probably be _____ a. igh calcium and phosphorus, acid ash c. 8ow calcium and phosphorus, acid ash b. igh calcium and phosphorus, alkaline ash d. 8ow calcium and phosphorus, alkaline ash
F O ! S: 1.
c.
A client is placed on a ' ( gram ( sodium diet.
ow much added salt is allowed per day% a. ? tbs b. ? tsp
c.
@ tbs
Which food group is lowest in sodium% a. 0eats b. )airy products
c. d.
resh fruits resh vegetables
d.
@ tsp
$ou teach him that salt substitutes cannot be used in the diet because _____ a. A persons body tends to retain fluid when a salt substitute is included in the diet b. 8imiting salt substitutes in the diet prevents a build up of waste products in the blood 2
c. d.
4.
5.
+alt substitutes contain potassium, which must be limited to prevent abnormal heartbeats A substance in the salt substitute interferes with the transfer of fluid across capillary membranes, resulting in anasarca
&he food label says sodium – free” . What does it mean% a. +odium is less than * g per serving c. b. +odium is less than * mg per serving d.
+odium is less than 5 g per serving +odium is less than 5 mg per serving
&he food has 599 mg of sodium per serving. &he same food prepared light in sodium” would haveB a. *C5 mg of sodium c. 159 mg of sodium b. #59 mg of sodium d. 199 mg of sodium
THERAPEUTIC COMMUNICATION 1. -aranoid patient tells the nurse on psyche unit &he food is poisoned.D Whats the appropriate response of the nurse% a. &he dietitian prepares the food. &hey wont put anything that will harm the patient.D b. &he other patients eat the same food and no ill effects are noted. c. ave you found anything unusual in the food%D
SUCTIONING Situation:
You have decided to perform nasopharyngeal suctioning for a conscious client #ho is unable to cough up and e)pectorate secretions.
1.
!efore doing this procedure, you should place him in which position% a. +emi owler with the neck hyper e3tended c. +emi owler with the head turned to one side b. 8ateral facing to you d. 8ateral facing away from you
#.
$ou should make an appro3imate measure of the depth for the insertion of the catheter. As such, you should measure the distance between _____ a. &he tip of his nose and the umbilicus c.&he tip of his nose and the suprasternal notch b. &he tip of his nose and the 3iphoid process d. &he tip of his nose and the earlobe
*.
While doing this procedure, you can avoid trauma to the mucous membrane by _____ a. -utting on the sterile gloves c. Applying no suction while inserting the catheter b. 8ubricating the catheter tip d. Wiping off the catheter with sterile gaue
4.
Which action is safe% a. "nsert the catheter appro3imately #9 cm while applying suction b. Allow #9 *9 sec intervals between each suction and limit suctioning to a total of 15 min c. /ently rotate the catheter while applying suction d. Apply suction for 5 sec while inserting the catheter and continue for another 5 sec before withdrawing
5.
Which finding would most likely indicate that the procedure is effective% a. (espirations unlabored c. )ecreased mucus production b. ollow sound on chest percussion d. !reath sounds clear on auscultation
F O ! S:
You are preparing to suction an adult*s tracheostomy tube.
1.
Which set of personal protective e6uipment E--F would you wear to perform this procedure% a. /own, mask, and sterile gloves c. 0ask, gown, and a cap b. /oggles, mask, and sterile gloves d. 0ask, sterile gloves, and a cap
#.
What is the recommended pressure setting for suctioning his tracheostomy tube% a. 49 =9 mm g c. 199 1#9 mm g b. =9 G9 mm g d. 1#9 149 mm g
*.
$ou should hypero3ygenate his lungs using a manual resuscitation bag basically because he doesnt have copious amounts of secretions and thus you should compress it _____ a. 1 * times, as he inhales c. 1 * times, as he e3hales b. * 5 times, as he inhales d. * 5 times, as he e3hales
4.
What is the ma)imum amount of time you should suction his tracheostomy tube% a. 19 seconds b. 15 seconds c. #5 seconds
5.
d.
*9 seconds
$ou should use intermittent suction primarily to help prevent _____ a. +timulating his cough refle3 c. )islodging his tracheostomy tube b. )epriving him of sufficient o3ygen supply d. 2bstructing the catheter with secretions
3
ASSESSMENT 1.
Which of the following times is ideal to assess a clients respirations% a. "mmediately after taking his body temperature b. Immediately after tai!" #i$ %&l$e rate c. "mmediately after taking his blood pressure d. Anytime during the assessment
#.
Which of the following components should receive the highest priority before a physical assessment% a. -hysical preparation of the client '. P$y'#(l("i'al %re%arati(! (f t#e 'lie!t b. -reparation of the environment d. -reparation of the e6uipment
*.
;tiliing the +2A- charting, the nurse would record her nursing diagnosis under which of the following% a. + +ub:ective '. A ) A$$e$$me!t b. 2 2b:ective d. - -lanning
4.
"n assessing adult vital signs, the nurse performs which of the following techni6ues% a. "nspection, -alpation, -ercussion c. -ercussion, Auscultation, "nspection b. -alpation, -ercussion, Auscultation d. A&$'<ati(!* I!$%e'ti(!* Pal%ati(!
5.
Which method for assessing temperature is the least accurate% a. 2ral '. b. (ectal d.
A+illary &ympanic
=. Which type of nursing diagnosis is one in which evidence about a health problem is incomplete or unclear which re6uires more data either to support or to refute it% a. Wellness diagnosis c. Actual diagnosis b. (isk nursing diagnosis d. P($$ible !&r$i!" dia"!($i$ C. Which statement describes what a nursing diagnosis does% a. "t provides a systemic, rational method of planning and providing nursing care b. It fa'ilitate$ a '(m%re#e!$i,e !&r$i!" 'are by ide!tifyi!" t#e #ealt# %r(blem a!d ,alidati!" t#e '(!trib&ti!" fa't(r c. "t includes assessment, diagnosis, planning, implementation, and evaluation d. "t provides a framework for nurse accountability and responsibility
DISCHARGE 1.
Which of the following times is ideal to begin discharge planning% a. #4 hours after discharge '. b. &he day before discharge d.
At t#e time (f admi$$i(! When the patient desires
#.
!efore discharge, 0ang Hash sister will demonstrate how to use the glucometer correctly. &his is an e3ample of what kind of ob:ectiveB a.7ognitive b. 8ong term c. ffective d. P$y'#(m(t(r
*.
!efore (ose is discharged she will be able to e3plain the pathophysiology of her illness and the different foods to be avoided. &his is an e3ample of which learning ob:ective% a. 0anagement b. -sychomotor c. Affective d. C("!iti,e
4. 0ost nurses regard this as conventional recording of the date, time, and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. "t is accepted that collaboration or multidisciplinary involvement Eof all members of the health teamF in discharge results in comprehensive care. What do you call this% a. Di$'#ar"e S&mmary c. 0edicine and &reatment (ecord b. Hursing'arde3 d. Hursing ealth istory and Assessment Worksheet
SATA ON CHARTING 1.
Which of the following 6ualities are relevant in documenting client care% 1. accuracy and conciseness #. thoroughness and currentness *. systematic and orderly 4. legibly, properly dated and signed 5. use of locally accepted abbreviation a.
#, *, 4 and 5
b.
-* * / a!d 0 4
c.
1, #, * and 5
d.
1, *, 4 and 5
#. While the nurse was doing her rounds, she discovered that a client is lying on the floor. Which of the following statements should appear in the documentation% +elect all that applyB A. T#e 'lie!t i$ f(&!d (! t#e fl((r D. T#e d('t(r #a$ bee! !(tified !. &he client probably fell from the bed . &he client is now in a safe environment C. T#e ,ital $i"!$ #a,e bee! '#e'ed
HANDLING HA1ARDOUS MATERIALS 1. What could be used to minimie electrical haard in the hospital% a.rayed cord '. T#ree %r(!"ed %l&" b.&wo pronged plug d. 2pen wirings #. &he most common haard associated with electricity in a procedure room is a. ire b. !urns '. Ele'tri' $#('
d. All of the above
*. Which of the following is a lead poisoning prevention discharge instruction% A. U$e '(ld 2ater f(r dri!i!". !. -revent washing of clothes using washing machine. 7. Ho sharing of clothes with siblings. ). Avoid undergoing multiple invasive procedures. (ationaleB Water that comes out of the tap warm or hot can contain much higher levels of lead.
TU3E 4EEDINGS Situation:
You are preparing to administer enteral tube feedings.
1.
$ou are preparing to administer continuous feedings. &he formula should be administered using _____ a. "nfusion pump c. "ntravenous filter b. /ravity drip d. &hree way stop cock
#.
What is the correct position for administering enteral tube feedings% a. 'eep the head of the bed flat c. -lace him in a left lying position b. levate the head of the bed *9 45I d. (aise the foot of the bed 19 J #9I
*.
$ou determine that the nasogastric tube is properly positioned after obtaining which p reading% a. 4 b. = c. C d. G
4.
e is to receive #99 m8 of tube feedings every 4 hours. $ou check for his gastric residual before administering the ne3t scheduled feeding and obtain 49 m8 of gastric residual, what is your most appropriate nursing intervention% a. Withhold the feeding and then recheck the residual after 1 hour b. )ispose of the residual and continue with the feeding c. )elay feeding him for 1 hour and then recheck the residual d. (e administer the residual to him and continue with the feeding
5.
e has developed diarrhea, cramps, and abdominal distention. All but which are appropriate nursing interventions% a. 0ake sure to change the feeding apparatus every #4 hr b. ;se a higher volume of formula because the formula may be too hypotonic c. +low the administration rate d. ;se a diluted formula gradually increasing the volume and concentration
TPN Situation:
You are caring for a client #ho*s receiving parenteral nutrition.
1.
What is the lowest amount of glucose considered safe and not caustic to small veins that will also provide ade6uate &-H when administering &-H through a peripheral "< line% a. 5K b. 19K c. 15K d. 1CK
#.
$ou notice that the bag of &-H solution has been infusing for #4 hours but has *99 m8 of solution left. What would be your most appropriate nursing action% a. 7ontinue the infusion until the remaining *99 m8 is infused b. 7hange the filter on the tubing and continue with the infusion c. Hotify the physician and obtain orders to alter the flow rate of the solution d. )iscontinue the current solution, change the tubing, and hang a new bag of &-H solution 5
*.
$ou note that the bag of &-H solution has become empty. $ou call the pharmacy, but the ne3t bag will not be delivered for another *9 minutes. $ou hang which solution until the &-H arrives% a. )5W b. )19W c. )59H+ d. ) 5H+
4.
Which observation best indicates he is having the desired therapeutic effects from &-H% a. e has regular bowel movements c. e is gaining weight b. e maintains blood sugars in the normal range d. e has normal urine output
5.
"f the &-H were abruptly discontinued, you would e3pect him to e3hibit _____ a. &innitus, vertigo, blurred vision c. )iaphoresis, confusion, tachycardia b. ever, malaise, anore3ia d. yperpnea, flushed face, diarrhea
F O ! S: +eripheral &ine basilic or cephalic vein used for * – + wee&s de)trose concentration in the solution is *,- to avoid irritation of blood vessel walls" phlebitis" and sclerosis/
entral &ine subclavian or %ugular vein used for 0 + wee&s de)trose concentration in the solution is 0 *,-
entral ,enous Access "evices -,A"s 1riple lumen catheter 2 “common” *3 4 middle lumen used for 15# infusion used when 15# needed 6 7 wee&s
5eripherally inserted central catheter 5I88/ 2 “increasingly popular” inserted into peripheral vein and advanced to superior vena cava used when 15# needed 0 7 wee&s
3LOOD TRANS4USION F O ! S:
/lood 0roup and 1h Type ompatibilities /lood 0roup 9 : ( :(
an be donor for 9" :" (" :( :" :( (" :( :(
an be recipient of 9 9" : 9" ( 9" :" (" :(
1h Type ; –
an be donor for ; ;" –
an be recipient of ;" – –
=====
ecipient 2 =====
6
Situation: 1.
You have received an order to transfuse a client #ith one unit of pac$ed red blood cells -1/s.
$ou should use an "< access device of which sie% a. 1G / b. #1 /
c.
#* /
d.
#5 /
#.
$ou are aware that the tubing is manufactured with which of the following% a. A microdrip chamber c. An in line filter b. An air vent d. &inting that protects blood from e3posure to light
*.
$ou would obtain which "< solution to hang with the unit of blood% a.(ingers lactate c.5K de3trose in 9.45K sodium chloride b.5K de3trose in 9.>K sodium chloride d.9.>K sodium chloride
4.
$ou must check the name on the label of the blood with the name on his _____ a. Wristband c. 0edical chart b. Wristband in the presence of another nurse d. 0edication administration record E0A(F
5.
$ou should stay with him for how long when the unit of blood is hung% a. 5 minutes b. * minutes c. @, minutes
F O ! S:
d.
7 minutes
Transfusion 1eaction Type Aypersensitivity 'ebrile Aemolytic
ause antibodies in donor blood nonspecific blood incompatibility
*st 2 195 transfusion + nd 2 BC9 with infusion of normal saline ,.D- #a 8l/ :ssess client and measure C as often as every minutes Situation:
You are preparing to administer a unit of pac$ed red blood cells -1/s on a client.
1.
$ou and another nurse have confirmed that it is the correct blood for him. "mmediately prior to starting the blood transfusion, you should assess which of the following% a.
#.
What is the average time for infusing a unit of packed red blood cells E(!7sF% a. *9 minutes b. 1 # hours c. # 4 hours
d.
4 = hours
*.
+hortly after the transfusion is started he complains of lower back pain. Which transfusion reaction is he probably e3periencing% a. ypersensitivity c. emolytic b. ebrile d. !acterial
4.
&he blood bag and a urine specimen are sent to the laboratory. &he reason for sending a urine specimen to the laboratory is to test for _____ a. +pecific gravity c. 7arbo3yhemoglobin b. ree hemoglobin d. )isseminated intravascular coagulation
5.
$ou document the event according to hospital policy and do which action with the remainder of the blood that has not been transfused% a. )iscards the blood in the appropriate biohaard bag b. (eturns the blood to the blood bank c. +ends the blood to the chemistry laboratory for analysis d. +ends the blood to the infection control department
TYPES O4 I54$ Situation: 1.
#.
You are preparing to start an intravenous infusion on a ne#ly admitted client.
Which area should you try first % a. !ack of the hand b. "nner aspect of the elbow
c. d.
"nner aspect of the forearm 2uter aspect of the forearm
!efore inserting the needle into a vein, you would apply a tourni6uet on his arm to accomplish which of the following% 7
a. b.
)istend the veins +tabilie the veins
c. d.
"mmobilie the arm 2cclude arterial circulation
*.
When should you remove it% a. When the skin has been cleansed b. As soon as the needle is in vein c. As soon as the needle is positioned under the skin d. When the needle has been secured with tape
4.
$ou have successfully inserted the needle into a vein. A few hours later, while assessing his intravenous insertion site, you note that the area is swollen, cool, pale, and causes him discomfort. $ou document which complication of intravenous therapy% a. 8ocal infiltration b. -hlebitis c. "nfection d. Air embolism
5.
Which a. b. c. d.
action should you take first % )iscontinue the intravenous infusion Apply a warm, moist compress to the intravenous site 7heck the intravenous infusion for patency Apply an ice pack to the intravenous site
ISOLATION PRECAUTION Situation:
The 2ospital Infection ontrol +ractices Advisory ommittee -2I+A of the " presented ne# guidelines for isolation precautions in hospitals in 3445. These guidelines designate t#o tiers of precautions: Tier 3: Standard +recautions and Tier ': Transmission ( /ased +recautions.
1.
"solation -recautions break the chain of infection by interfering with which link% a. tiologic Agent c. 0ode of &ransmission b. -ortal of 3it d. +usceptible ost
#.
Which # phrases are true about Airborne -recautions% ". 8ess than 5 microns "". 0ore than 5 microns """. (emains in the air "<. +ettles to the floor a.
*.
" """
b.
"" """
c.
" "<
d.
"" "<
d.
"" "<
Which # phrases are true about )roplet -recautions% ". 8ess than * feet "". 0ore than * feet """. Wear a mask at all times "<. Wear a mask only when working within * feet of the client a.
" """
b.
"" """
c.
" "<
4.
Which type of mask is appropriate for you to use when caring directly for clients placed on Airborne -recautions% a. /as mask c. H >5 mask b. +urgical mask d. Any mask as long as you can breathe normally
5.
When caring for a client with diphtheria, you know that which type of precautions is re6uired% a. Airborne -recautions c. 7ontact -recautions b. )roplet -recautions d. +tandard -recautions
F O ! S:
Y(& are admitti!" a! imm&!('(m%r(mi$ed 'lie!t 2it# 'a!'er.
1.
$ou would consider implementing neutropenic precautions when white blood cell EW!7F count is _____ a. 19,599Lmm* b. C,=59Lmm* c. =,999Lmm* d. #,999Lmm*
#.
$ou understand precautionary measures necessary when you admit him to which room% a. A semiprivate room with a client who has pneumonia b. A private room with contact isolation c. A private room with protective isolation d. A private room with no isolation precautions
*.
$ou should be aware that >is& for InfectionD is high when white blood cell EW!7F count is _____ a. Hormal b. 8ow c. 0oderate d. igh
4.
$ou recognie that which is the most reliable early indicator of infection in a neutropenic client% a. ever b. 7hills c. &achycardia d.
5.
&achypnea
)uring evening visitation, a visitor brings in a fruit basket. What is your best action% a. Allow him to keep the fruit 8
b. c. d.
-lace the fruit ne3t to the bed for easy access by him 2ffer to wash the fruit for him (emove the fruit from his room
NURSING PROCESS Situation:
1.
The nursing process has uni6ue characteristics that enable responsiveness to the changing health status of the client.
Which range of applications does the nursing process have% a. Harrow b. 3act c.
)istinct d.
!road
#.
Which type of assessment is used to collect data about a specific problem that has been identified in an earlier assessment% a. "nitial assessment c. &ime lapsed reassessment b. ocus assessment d. mergency assessment
*.
Which type of nursing diagnosis is one in which evidence about a health problem is incomplete or unclear which re6uires more data either to support or to refute it% a. Wellness diagnosis c. Actual diagnosis b. (isk nursing diagnosis d. -ossible nursing diagnosis
4.
Which is the “product” developed during the planning phase of the nursing process% a. Hursing care plan c. Hursing history b. Hursing diagnoses d. Hursing notes
5.
$ou do which task in the implementing phase of the nursing process% a. )etermines the clients health status c. 0easures goal achievement b. "dentifies available resources d. -uts the nursing care plan into action
IMCI 1. Which of the following is not a danger sign% A. 7onvulsions !. "nability to drink or breastfeed
7. lethargy
D. diffi'<y breat#i!"
#. &he first child who is 1* months has fast breathing, using "07" parameters he hasB A. 06 breat#$ %er mi!&te (r m(re 7. *9 breaths per minute or more !. 59 breaths per minute or more ). =9 breaths per minute or more *. &he following follow up 6uestions will be used if the child presents with history or feels hot or with temperature of *C.597 and above, e3cept forB A. "f fever is present, then for how long% !. "f more than C days, has fever been present everyday% C. Ha$ t#e '#ild #ad mea$le$ f(r t#e %a$t 7 m(!t#$8 ). )oes the child have stiff neck% 4. 2n assessment, her cornea is cloudy with e3tensive mouth ulcers. 0rs.Alcantara e3claims she cant get her to eat anything and she is deeply worried about her child. 0ios condition is classified asB A. Se,ere '(m%li'ated mea$le$ !. 0easles with eye or mouth complications 7. 0easles ). 7omplicated measles 5. &he main parameter in classifying a child under the pink row of ear problems isB A. -us seen draining form the ears for more than 14 days. !. +evere pain in the ear. 7. Te!der $2elli!" be#i!d t#e ear. ). ar discharges for less than 14 days with fever.
ETHICS 1. !ased on the 7ode of thics for ilipino Hurses, what is regarded as the hallmark of nursing responsibility and accountability% A. Healt#* bei!" a f&!dame!tal ri"#t (f e,ery i!di,id&al !. Accurate documentation of actions and outcomes 7. uman rights of clients, regardless of creed and gender ). &he privilege of being a registered professional nurses #. A nurse is asked to keep the clients cancer progression from family members indefinitely. &his will re6uire the nurse to withhold information from the clients spouse, who fre6uently accompanies the client to the theory of 'antianism% a. &he nurse persuades the client to tell the family because it is the right thing to do b. T#e !&r$e '(!$ider$ m<i%le et#i'al %ri!'i%le$ a!d $&%%(rt$ t#e 'lie!t i! telli!" t#e family* a$ $#(&ld be d(!e &!i,er$ally i$ $&'# a $it&ati(! 9
c. &he nurse remembers the ethical rule of truth telling and decides to tell the clients spouse is secret d. &he nurse considers multiple ethical principles and does not tell the family, because client confidentiality is of primary importance *. After the physician e3plains the surgery to the client, the nurse provides the client with information about surgery, answers the clients 6uestions, and allows the client to agree or refuse to have surgery. Which of the following ethical principles is best described by the nurses actions% a. Honmaleficence b. !eneficence c. &ruth telling d. A&t(!(my 4. &he nurse informs a young, healthy client that the scarce amount of flu vaccine will be given to older clients and those with immunosuppressed responses first. Which of the following ethical principles is best described by the nurses statement% a. !eneficence b. Autonomy '. 9&$ti'e d. Honmaleficence 5. &he nurse returns to the clients room in e 3actly four hours to administer the ne3t dose of pain medication as p romised. Which of the following ethical rules is best demonstrated by the nurse% a. Mustice b. Honmaleficence '. 4idelity d. 7onfidentiality
RESEARCH 1. )eriving a propositional statement from theory involves the logical reasoning process calledN A. Ded&'ti,e 7. "nduction !. 7onceptualiation ). 7ritical analysis #. A set of shared understandings and assumptions about reality and the worldD is a definition for A. A concept 7. A practice discipline !. A conceptual frameworks D. A %aradi"m *. &he conclusions of a study are based on the A. 4i!di!"$ (f t#e $t&dy !. (eview of the literature
7. "mplications of the study ). (ecommendations for future research
4. A new public health nurse would like to collect data on common problems encountered by diabetic patients in the community. "n this survey, she selects only the diabetic patients in the community. "n this survey, she selects only the diabetic residing in the different barangays of the community where she was assigned. &his is an e3ample of what type of sampling% a. P&r%($i,e b. 7luster c. +ystematic d. +tratified 5. Which of the following items distinguishes true e3perimental research from 6uasiJ e3perimental research% A. +ie e3ample !. &he use of a nonprobability sample C. Ra!d(m a$$i"!me!t$ (f $&b:e't$ t( "r(&%$ ). &he introduction of an e3perimental treatment
COMMUNICATION 1.
!efore making an initial contact with the clients, the nurse decides to review their individual medical records. &his phase of the nurse patient relationship could best be referred to as theB a. Pre ) i!tera'ti(! %#a$e c. Working phase b. 2rientation phase d. &ermination phase
#.
"n demonstrating the method for deep breathing e3ercises, the nurse places the hands on the clients abdomen to e3plain diaphragmatic movement. &his techni6ue involves the use of which element of communication% a. 0essage c. Appropriateness b. eedback d. C#a!!el
*.
7ommunication can be verbal and non verbal. 3amples of non verbal communication in nurse client relationship are the following e3ceptB a. using a sign language interpreter like a family member b. signs c. restlessness d. $ym%t(m$
4.
"nterpersonal communication is least threatening during what type of relationship% a. "ntimate c. -rofessional b. S('ial d. -ersonal 5.
Which of the following nursing interventions would be most appropriate for facilitating communication with a client who has hearing impairment% a. When speaking, stand to one side of the client and direct the voice directly into the clients ear b. +tand close to the client and speak as loudly as possible '. Sta!d i! fr(!t (f t#e 'lie!t a!d $%ea $l(2ly a!d 'learly 10
d.
Ask only 6uestions that the client can answer with a yesD or noD response
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