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Fundamentals of Nursing Practice Exam 3 (PM)
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Question 1
When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
A
Cuffs of the gown
B
Waist tie in front of the gown
C
Waist tie and neck tie at the back of the gown
D
Inside of the gown
Question 1 Explanation:
The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.
Question 2
The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
A
25 gtt/minute
B
50 gtt/minute
C
5 gtt/minute
D
13 gtt/minute
Question 2 Explanation:
100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
Question 3
The two blood vessels most commonly used for TPN infusion are the:
A
Femoral and subclavian veins
B
Brachial and femoral veins
C
Brachial and subclavian veins
D
Subclavian and jugular veins
Question 3 Explanation:
Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.
Question 4
Which of the following procedures always requires surgical asepsis?
A
Urinary catheterization
B
Nasogastric tube insertion
C
Colostomy irrigation
D
Vaginal instillation of conjugated estrogen
Question 4 Explanation:
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.
Question 5
Which of the following statements about chest X-ray is false?
A
A signed consent is not required
B
Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
C
No contradictions exist for this test
D
Eating, drinking, and medications are allowed before this test
Question 5 Explanation:
Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
Question 6
An infected patient has chills and begins shivering. The best nursing intervention is to:
A
Provide increased cool liquids
B
Apply iced alcohol sponges
C
Provide increased ventilation
D
Provide additional bedclothes
Question 6 Explanation:
In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
Question 7
All of the following are common signs and symptoms of phlebitis except:
A
Frank bleeding at the insertion site
B
A red streak exiting the IV insertion site
C
Pain or discomfort at the IV insertion site
D
Edema and warmth at the IV insertion site
Question 7 Explanation:
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
Question 8
Immobility impairs bladder elimination, resulting in such disorders as
A
Urine retention, bladder distention, and infection
B
Increased urine acidity and relaxation of the perineal muscles, causing incontinence
C
Decreased calcium and phosphate levels in the urine
D
Diuresis, natriuresis, and decreased urine specific gravity
Question 8 Explanation:
The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.
Question 9
Which of the following blood tests should be performed before a blood transfusion?
A
Blood typing and cross-matching
B
Prothrombin and coagulation time
C
Complete blood count (CBC) and electrolyte levels.
D
Bleeding and clotting time
Question 9 Explanation:
Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.
Question 10
Thrombophlebitis typically develops in patients with which of the following conditions?
A
Increases partial thromboplastin time
B
Chronic Obstructive Pulmonary Disease (COPD)
C
An impaired or traumatized blood vessel wall
D
Acute pulsus paradoxus
Question 10 Explanation:
The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.
Question 11
The purpose of increasing urine acidity through dietary means is to:
A
Decrease burning sensations
B
Inhibit the growth of microorganisms
C
Change the urine’s concentration
D
Change the urine’s color
Question 11 Explanation:
Microorganisms usually do not grow in an acidic environment.
Question 12
The mid-deltoid injection site is seldom used for I.M. injections because it:
A
Can be used only when the patient is lying down
B
Does not readily parenteral medication
C
Can accommodate only 1 ml or less of medication
D
Bruises too easily
Question 12 Explanation:
The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).
Question 13
Which element in the circular chain of infection can be eliminated by preserving skin integrity?
A
Mode of transmission
B
Portal of entry
C
Host
D
Reservoir
Question 13 Explanation:
In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.
Question 14
All of the following are good sources of vitamin A except:
A
White potatoes
B
Carrots
C
Egg yolks
D
Apricots
Question 14 Explanation:
The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
Question 15
Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
A
Chest pain
B
Hemoglobinuria
C
Urticaria
D
Distended neck veins
Question 15 Explanation:
Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia.
Question 16
In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
A
Assessment
B
Evaluation
C
Planning
D
Analysis
Question 16 Explanation:
In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.
Question 17
Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
A
10,000/mm³
B
4,500/mm³
C
7,000/mm³
D
25,000/mm³
Question 17 Explanation:
Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.
Question 18
Effective skin disinfection before a surgical procedure includes which of the following methods?
A
Having the patient take a tub bath on the morning of surgery
B
Applying a topical antiseptic to the skin on the evening before surgery
C
Shaving the site on the day before surgery
D
Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery
Question 18 Explanation:
Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away.
Question 19
The appropriate needle size for insulin injection is:
A
22G, 1” long
B
25G, 5/8” long
C
22G, 1 ½” long
D
18G, 1 ½” long
Question 19 Explanation:
A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
Question 20
Which of the following nursing interventions is considered the most effective form or universal precautions?
A
Discard all used uncapped needles and syringes in an impenetrable protective container
B
Wear gloves when administering IM injections
C
Follow enteric precautions
D
Cap all used needles before removing them from their syringes
Question 20 Explanation:
According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
Question 21
The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:
A
Have the patient repeat the nurse’s instructions using her own words
B
Demonstrate the procedure to the patient and encourage to ask questions
C
Ask the patient to demonstrate the procedure
D
Ask the patient if he/she has used ear drops before
Question 21 Explanation:
Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.
Question 22
A patient who develops hives after receiving an antibiotic is exhibiting drug:
A
Idiosyncrasy
B
Synergism
C
Tolerance
D
Allergy
Question 22 Explanation:
A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects.
Question 23
Clay colored stools indicate:
A
Impending constipation
B
Upper GI bleeding
C
An effect of medication
D
Bile obstruction
Question 23 Explanation:
Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.
Question 24
Which of the following conditions may require fluid restriction?
A
Fever
B
Renal Failure
C
Dehydration
D
Chronic Obstructive Pulmonary Disease
Question 24 Explanation:
In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.
Question 25
A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:
A
Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B
Order a hemoglobin and hematocrit count 1 hour after the arteriography
C
Assess a vital signs every 15 minutes for 2 hours
D
Check the pressure dressing for sanguineous drainage
Question 25 Explanation:
A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
Question 26
When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
A
Leg muscles
B
Abdominal muscles
C
Upper arm muscles
D
Back muscles
Question 26 Explanation:
The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.
Question 27
Which of the following types of medications can be administered via gastrostomy tube?
A
Most tablets designed for oral use, except for extended-duration compounds
B
Capsules whole contents are dissolve in water
C
Any oral medications
D
Enteric-coated tablets that are thoroughly dissolved in water
Question 27 Explanation:
Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.
Question 28
After routine patient contact, hand washing should last at least:
A
2 minute
B
3 minutes
C
1 minute
D
30 seconds
Question 28 Explanation:
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.
Question 29
Effective hand washing requires the use of:
A
Soap or detergent to promote emulsification
B
All of the above
C
Hot water to destroy bacteria
D
A disinfectant to increase surface tension
Question 29 Explanation:
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.
Question 30
Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A
Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
B
Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
C
Irrigate the patient with 1% Neosporin solution three times a daily
D
Maintain the drainage tubing and collection bag level with the patient’s bladder
Question 30 Explanation:
Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
Question 31
Sterile technique is used whenever:
A
Strict isolation is required
B
Terminal disinfection is performed
C
Invasive procedures are performed
D
Protective isolation is necessary
Question 31 Explanation:
All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.
Question 32
All of the following statement are true about donning sterile gloves except:
A
The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist
B
The first glove should be picked up by grasping the inside of the cuff.
C
The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
D
The inside of the glove is considered sterile
Question 32 Explanation:
The inside of the glove is always considered to be clean, but not sterile.
Question 33
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:
A
Anorexia
B
Hypokalemia
C
Hyperkalemia
D
Dysphagia
Question 33 Explanation:
Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.
Question 34
The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
A
60 mg
B
0.6 mg
C
600 mg
D
10 mg
Question 34 Explanation:
gr 10 x 60mg/gr 1 = 600 mg
Question 35
The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A
After chest physiotherapy
B
After aerosol therapy
C
After the patient eats a light breakfast
D
Early in the morning
Question 35 Explanation:
Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.
Question 36
All of the following measures are recommended to prevent pressure ulcers except:
A
Massaging the reddened are with lotion
B
Providing meticulous skin care
C
Using a water or air mattress
D
Adhering to a schedule for positioning and turning
Question 36 Explanation:
Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.
Question 37
The correct method for determining the vastus lateralis site for I.M. injection is to:
A
Divide 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
B
Palpate a 1” circular area anterior to the umbilicus
C
Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
D
Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
Question 37 Explanation:
The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.
Question 38
Which of the following will probably result in a break in sterile technique for respiratory isolation?
A
Turning on the patient’s room ventilator
B
Failing to wear gloves when administering a bed bath
C
Opening the door of the patient’s room leading into the hospital corridor
D
Opening the patient’s window to the outside environment
Question 38 Explanation:
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 desirable. The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation.
Question 39
Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
A
Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container
B
Touching the outside wrapper of sterilized material without sterile gloves
C
Placing a sterile object on the edge of the sterile field
D
Using sterile forceps, rather than sterile gloves, to handle a sterile item
Question 39 Explanation:
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.
Question 40
Which of the following patients is at greater risk for contracting an infection?
A
A newly diagnosed diabetic patient
B
A patient receiving broad-spectrum antibiotics
C
A patient with leukopenia
D
A postoperative patient who has undergone orthopedic surgery
Question 40 Explanation:
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.
Question 41
In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A
Appneustic breathing, atypical pneumonia and respiratory alkalosis
B
Cheyne-Strokes respirations and spontaneous pneumothorax
C
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
D
Kussmail’s respirations and hypoventilation
Question 41 Explanation:
Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
Question 42
A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
A
Apply corn starch soaks to the rash
B
Withhold the moderation and notify the physician
C
Administer the medication with an antihistamine
D
Administer the medication and notify the physician
Question 42 Explanation:
Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.
Question 43
The appropriate needle gauge for intradermal injection is:
A
26G
B
22G
C
25G
D
20G
Question 43 Explanation:
Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
Question 44
The nurse explains to a patient that a cough:
A
Is primarily a voluntary action
B
Is a protective response to clear the respiratory tract of irritants
C
Is induced by the administration of an antitussive drug
D
Can be inhibited by “splinting” the abdomen
Question 44 Explanation:
Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs.
Question 45
A clinical nurse specialist is a nurse who has:
A
Received credentials from the Philippine Nurses’ Association
B
Been certified by the National League for Nursing
C
Graduated from an associate degree program and is a registered professional nurse
D
Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
Question 45 Explanation:
A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.
Question 46
The ELISA test is used to:
A
Screen blood donors for antibodies to human immunodeficiency virus (HIV)
B
Aid in diagnosing a patient with AIDS
C
Test blood to be used for transfusion for HIV antibodies
D
All of the above
Question 46 Explanation:
The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
Question 47
A natural body defense that plays an active role in preventing infection is:
A
Rapid eye movements
B
Yawning
C
Hiccupping
D
Body hair
Question 47 Explanation:
Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.
Question 48
The primary purpose of a platelet count is to evaluate the:
A
Presence of an antigen-antibody response
B
Potential for clot formation
C
Potential for bleeding
D
Presence of cardiac enzymes
Question 48 Explanation:
Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
Question 49
All of the following nursing interventions are correct when using the Z-track method of drug injection except:
A
Prepare the injection site with alcohol
B
Aspirate for blood before injection
C
Rub the site vigorously after the injection to promote absorption
D
Use a needle that’s a least 1” long
Question 49 Explanation:
The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.
Question 50
Parenteral penicillin can be administered as an:
A
Intradermal or subcutaneous injection
B
IM or a subcutaneous injection
C
IV or an intradermal injection
D
IM injection or an IV solution
Question 50 Explanation:
Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
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Fundamentals of Nursing Practice Exam 3 (EM)
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Question 1
All of the following are good sources of vitamin A except:
A
Apricots
B
Carrots
C
Egg yolks
D
White potatoes
Question 1 Explanation:
The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
Question 2
In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
B
Appneustic breathing, atypical pneumonia and respiratory alkalosis
C
Cheyne-Strokes respirations and spontaneous pneumothorax
D
Kussmail’s respirations and hypoventilation
Question 2 Explanation:
Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
Question 3
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:
A
Anorexia
B
Hyperkalemia
C
Hypokalemia
D
Dysphagia
Question 3 Explanation:
Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.
Question 4
The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:
A
Ask the patient if he/she has used ear drops before
B
Have the patient repeat the nurse’s instructions using her own words
C
Demonstrate the procedure to the patient and encourage to ask questions
D
Ask the patient to demonstrate the procedure
Question 4 Explanation:
Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.
Question 5
The correct method for determining the vastus lateralis site for I.M. injection is to:
A
Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
B
Divide 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
C
Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
D
Palpate a 1” circular area anterior to the umbilicus
Question 5 Explanation:
The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.
Question 6
The purpose of increasing urine acidity through dietary means is to:
A
Inhibit the growth of microorganisms
B
Change the urine’s color
C
Decrease burning sensations
D
Change the urine’s concentration
Question 6 Explanation:
Microorganisms usually do not grow in an acidic environment.
Question 7
Which of the following nursing interventions is considered the most effective form or universal precautions?
A
Follow enteric precautions
B
Wear gloves when administering IM injections
C
Discard all used uncapped needles and syringes in an impenetrable protective container
D
Cap all used needles before removing them from their syringes
Question 7 Explanation:
According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
Question 8
The nurse explains to a patient that a cough:
A
Is primarily a voluntary action
B
Is a protective response to clear the respiratory tract of irritants
C
Can be inhibited by “splinting” the abdomen
D
Is induced by the administration of an antitussive drug
Question 8 Explanation:
Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs.
Question 9
Which element in the circular chain of infection can be eliminated by preserving skin integrity?
A
Portal of entry
B
Host
C
Mode of transmission
D
Reservoir
Question 9 Explanation:
In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.
Question 10
The primary purpose of a platelet count is to evaluate the:
A
Potential for clot formation
B
Potential for bleeding
C
Presence of an antigen-antibody response
D
Presence of cardiac enzymes
Question 10 Explanation:
Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
Question 11
The appropriate needle gauge for intradermal injection is:
A
25G
B
22G
C
20G
D
26G
Question 11 Explanation:
Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
Question 12
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
Failing to wear gloves when administering a bed bath
C
Opening the door of the patient’s room leading into the hospital corridor
D
Turning on the patient’s room ventilator
Question 12 Explanation:
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 desirable. The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation.
Question 13
An infected patient has chills and begins shivering. The best nursing intervention is to:
A
Provide additional bedclothes
B
Provide increased cool liquids
C
Apply iced alcohol sponges
D
Provide increased ventilation
Question 13 Explanation:
In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
Question 14
All of the following measures are recommended to prevent pressure ulcers except:
A
Adhering to a schedule for positioning and turning
B
Massaging the reddened are with lotion
C
Using a water or air mattress
D
Providing meticulous skin care
Question 14 Explanation:
Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.
Question 15
The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
A
50 gtt/minute
B
13 gtt/minute
C
5 gtt/minute
D
25 gtt/minute
Question 15 Explanation:
100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
Question 16
The ELISA test is used to:
A
Screen blood donors for antibodies to human immunodeficiency virus (HIV)
B
All of the above
C
Test blood to be used for transfusion for HIV antibodies
D
Aid in diagnosing a patient with AIDS
Question 16 Explanation:
The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
Question 17
After routine patient contact, hand washing should last at least:
A
2 minute
B
1 minute
C
30 seconds
D
3 minutes
Question 17 Explanation:
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.
Question 18
Sterile technique is used whenever:
A
Protective isolation is necessary
B
Strict isolation is required
C
Terminal disinfection is performed
D
Invasive procedures are performed
Question 18 Explanation:
All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.
Question 19
Thrombophlebitis typically develops in patients with which of the following conditions?
A
An impaired or traumatized blood vessel wall
B
Chronic Obstructive Pulmonary Disease (COPD)
C
Increases partial thromboplastin time
D
Acute pulsus paradoxus
Question 19 Explanation:
The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.
Question 20
Which of the following blood tests should be performed before a blood transfusion?
A
Blood typing and cross-matching
B
Prothrombin and coagulation time
C
Complete blood count (CBC) and electrolyte levels.
D
Bleeding and clotting time
Question 20 Explanation:
Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.
Question 21
Effective hand washing requires the use of:
A
Hot water to destroy bacteria
B
All of the above
C
Soap or detergent to promote emulsification
D
A disinfectant to increase surface tension
Question 21 Explanation:
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.
Question 22
Parenteral penicillin can be administered as an:
A
IM or a subcutaneous injection
B
IM injection or an IV solution
C
IV or an intradermal injection
D
Intradermal or subcutaneous injection
Question 22 Explanation:
Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
Question 23
The appropriate needle size for insulin injection is:
A
25G, 5/8” long
B
22G, 1 ½” long
C
22G, 1” long
D
18G, 1 ½” long
Question 23 Explanation:
A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
Question 24
Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
A
10,000/mm³
B
7,000/mm³
C
4,500/mm³
D
25,000/mm³
Question 24 Explanation:
Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.
Question 25
All of the following are common signs and symptoms of phlebitis except:
A
A red streak exiting the IV insertion site
B
Frank bleeding at the insertion site
C
Edema and warmth at the IV insertion site
D
Pain or discomfort at the IV insertion site
Question 25 Explanation:
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
Question 26
A natural body defense that plays an active role in preventing infection is:
A
Yawning
B
Rapid eye movements
C
Body hair
D
Hiccupping
Question 26 Explanation:
Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.
Question 27
Which of the following conditions may require fluid restriction?
A
Renal Failure
B
Dehydration
C
Chronic Obstructive Pulmonary Disease
D
Fever
Question 27 Explanation:
In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.
Question 28
All of the following nursing interventions are correct when using the Z-track method of drug injection except:
A
Prepare the injection site with alcohol
B
Aspirate for blood before injection
C
Rub the site vigorously after the injection to promote absorption
D
Use a needle that’s a least 1” long
Question 28 Explanation:
The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.
Question 29
A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
A
Administer the medication and notify the physician
B
Apply corn starch soaks to the rash
C
Withhold the moderation and notify the physician
D
Administer the medication with an antihistamine
Question 29 Explanation:
Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.
Question 30
Which of the following patients is at greater risk for contracting an infection?
A
A newly diagnosed diabetic patient
B
A patient receiving broad-spectrum antibiotics
C
A patient with leukopenia
D
A postoperative patient who has undergone orthopedic surgery
Question 30 Explanation:
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.
Question 31
Clay colored stools indicate:
A
Impending constipation
B
Bile obstruction
C
An effect of medication
D
Upper GI bleeding
Question 31 Explanation:
Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.
Question 32
A patient who develops hives after receiving an antibiotic is exhibiting drug:
A
Idiosyncrasy
B
Allergy
C
Tolerance
D
Synergism
Question 32 Explanation:
A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects.
Question 33
Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A
Maintain the drainage tubing and collection bag level with the patient’s bladder
B
Irrigate the patient with 1% Neosporin solution three times a daily
C
Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D
Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
Question 33 Explanation:
Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
Question 34
When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
A
Back muscles
B
Upper arm muscles
C
Leg muscles
D
Abdominal muscles
Question 34 Explanation:
The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.
Question 35
Which of the following procedures always requires surgical asepsis?
A
Urinary catheterization
B
Nasogastric tube insertion
C
Vaginal instillation of conjugated estrogen
D
Colostomy irrigation
Question 35 Explanation:
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.
Question 36
Effective skin disinfection before a surgical procedure includes which of the following methods?
A
Shaving the site on the day before surgery
B
Having the patient take a tub bath on the morning of surgery
C
Applying a topical antiseptic to the skin on the evening before surgery
D
Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery
Question 36 Explanation:
Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away.
Question 37
The mid-deltoid injection site is seldom used for I.M. injections because it:
A
Can be used only when the patient is lying down
B
Can accommodate only 1 ml or less of medication
C
Bruises too easily
D
Does not readily parenteral medication
Question 37 Explanation:
The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).
Question 38
Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
A
Hemoglobinuria
B
Urticaria
C
Chest pain
D
Distended neck veins
Question 38 Explanation:
Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia.
Question 39
When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
A
Waist tie in front of the gown
B
Cuffs of the gown
C
Inside of the gown
D
Waist tie and neck tie at the back of the gown
Question 39 Explanation:
The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.
Question 40
The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
A
60 mg
B
0.6 mg
C
600 mg
D
10 mg
Question 40 Explanation:
gr 10 x 60mg/gr 1 = 600 mg
Question 41
In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
A
Assessment
B
Evaluation
C
Planning
D
Analysis
Question 41 Explanation:
In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.
Question 42
Which of the following types of medications can be administered via gastrostomy tube?
A
Most tablets designed for oral use, except for extended-duration compounds
B
Enteric-coated tablets that are thoroughly dissolved in water
C
Capsules whole contents are dissolve in water
D
Any oral medications
Question 42 Explanation:
Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.
Question 43
The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A
Early in the morning
B
After chest physiotherapy
C
After aerosol therapy
D
After the patient eats a light breakfast
Question 43 Explanation:
Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.
Question 44
Which of the following statements about chest X-ray is false?
A
A signed consent is not required
B
Eating, drinking, and medications are allowed before this test
C
No contradictions exist for this test
D
Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
Question 44 Explanation:
Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
Question 45
A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:
A
Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B
Check the pressure dressing for sanguineous drainage
C
Order a hemoglobin and hematocrit count 1 hour after the arteriography
D
Assess a vital signs every 15 minutes for 2 hours
Question 45 Explanation:
A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
Question 46
Immobility impairs bladder elimination, resulting in such disorders as
A
Urine retention, bladder distention, and infection
B
Diuresis, natriuresis, and decreased urine specific gravity
C
Decreased calcium and phosphate levels in the urine
D
Increased urine acidity and relaxation of the perineal muscles, causing incontinence
Question 46 Explanation:
The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.
Question 47
All of the following statement are true about donning sterile gloves except:
A
The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
B
The inside of the glove is considered sterile
C
The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist
D
The first glove should be picked up by grasping the inside of the cuff.
Question 47 Explanation:
The inside of the glove is always considered to be clean, but not sterile.
Question 48
Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
A
Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container
B
Using sterile forceps, rather than sterile gloves, to handle a sterile item
C
Touching the outside wrapper of sterilized material without sterile gloves
D
Placing a sterile object on the edge of the sterile field
Question 48 Explanation:
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.
Question 49
A clinical nurse specialist is a nurse who has:
A
Graduated from an associate degree program and is a registered professional nurse
B
Received credentials from the Philippine Nurses’ Association
C
Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
D
Been certified by the National League for Nursing
Question 49 Explanation:
A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.
Question 50
The two blood vessels most commonly used for TPN infusion are the:
A
Femoral and subclavian veins
B
Subclavian and jugular veins
C
Brachial and femoral veins
D
Brachial and subclavian veins
Question 50 Explanation:
Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.
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Text Mode – Text version of the exam
1. Which element in the circular chain of infection can be eliminated by preserving skin integrity?
Host
Reservoir
Mode of transmission
Portal of entry
2. Which of the following will probably result in a break in sterile technique for respiratory isolation?
Opening the patient’s window to the outside environment
Turning on the patient’s room ventilator
Opening the door of the patient’s room leading into the hospital corridor
Failing to wear gloves when administering a bed bath
3. Which of the following patients is at greater risk for contracting an infection?
A patient with leukopenia
A patient receiving broad-spectrum antibiotics
A postoperative patient who has undergone orthopedic surgery
A newly diagnosed diabetic patient
4. Effective hand washing requires the use of:
Soap or detergent to promote emulsification
Hot water to destroy bacteria
A disinfectant to increase surface tension
All of the above
5. After routine patient contact, hand washing should last at least:
30 seconds
1 minute
2 minute
3 minutes
6. Which of the following procedures always requires surgical asepsis?
Vaginal instillation of conjugated estrogen
Urinary catheterization
Nasogastric tube insertion
Colostomy irrigation
7. Sterile technique is used whenever:
Strict isolation is required
Terminal disinfection is performed
Invasive procedures are performed
Protective isolation is necessary
8. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
Using sterile forceps, rather than sterile gloves, to handle a sterile item
Touching the outside wrapper of sterilized material without sterile gloves
Placing a sterile object on the edge of the sterile field
Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container
9. A natural body defense that plays an active role in preventing infection is:
Yawning
Body hair
Hiccupping
Rapid eye movements
10. All of the following statement are true about donning sterile gloves except:
The first glove should be picked up by grasping the inside of the cuff.
The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist
The inside of the glove is considered sterile
11. When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
Waist tie and neck tie at the back of the gown
Waist tie in front of the gown
Cuffs of the gown
Inside of the gown
12. Which of the following nursing interventions is considered the most effective form or universal precautions?
Cap all used needles before removing them from their syringes
Discard all used uncapped needles and syringes in an impenetrable protective container
Wear gloves when administering IM injections
Follow enteric precautions
13. All of the following measures are recommended to prevent pressure ulcers except:
Massaging the reddened are with lotion
Using a water or air mattress
Adhering to a schedule for positioning and turning
Providing meticulous skin care
14. Which of the following blood tests should be performed before a blood transfusion?
Prothrombin and coagulation time
Blood typing and cross-matching
Bleeding and clotting time
Complete blood count (CBC) and electrolyte levels.
15. The primary purpose of a platelet count is to evaluate the:
Potential for clot formation
Potential for bleeding
Presence of an antigen-antibody response
Presence of cardiac enzymes
16. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
4,500/mm³
7,000/mm³
10,000/mm³
25,000/mm³
17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:
Hypokalemia
Hyperkalemia
Anorexia
Dysphagia
18. Which of the following statements about chest X-ray is false?
No contradictions exist for this test
Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
A signed consent is not required
Eating, drinking, and medications are allowed before this test
19. The most appropriate time for the nurse to obtain a sputum specimen for culture is:
Early in the morning
After the patient eats a light breakfast
After aerosol therapy
After chest physiotherapy
20. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
Withhold the moderation and notify the physician
Administer the medication and notify the physician
Administer the medication with an antihistamine
Apply corn starch soaks to the rash
21. All of the following nursing interventions are correct when using the Z-track method of drug injection except:
Prepare the injection site with alcohol
Use a needle that’s a least 1” long
Aspirate for blood before injection
Rub the site vigorously after the injection to promote absorption
22. The correct method for determining the vastus lateralis site for I.M. injection is to:
Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
Palpate a 1” circular area anterior to the umbilicus
Divide 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
23. The mid-deltoid injection site is seldom used for I.M. injections because it:
Can accommodate only 1 ml or less of medication
Bruises too easily
Can be used only when the patient is lying down
Does not readily parenteral medication
24. The appropriate needle size for insulin injection is:
18G, 1 ½” long
22G, 1” long
22G, 1 ½” long
25G, 5/8” long
25. The appropriate needle gauge for intradermal injection is:
20G
22G
25G
26G
26. Parenteral penicillin can be administered as an:
IM injection or an IV solution
IV or an intradermal injection
Intradermal or subcutaneous injection
IM or a subcutaneous injection
27. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
0.6 mg
10 mg
60 mg
600 mg
28. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
5 gtt/minute
13 gtt/minute
25 gtt/minute
50 gtt/minute
29. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
Hemoglobinuria
Chest pain
Urticaria
Distended neck veins
30. Which of the following conditions may require fluid restriction?
Fever
Chronic Obstructive Pulmonary Disease
Renal Failure
Dehydration
31. All of the following are common signs and symptoms of phlebitis except:
Pain or discomfort at the IV insertion site
Edema and warmth at the IV insertion site
A red streak exiting the IV insertion site
Frank bleeding at the insertion site
32. The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:
Ask the patient if he/she has used ear drops before
Have the patient repeat the nurse’s instructions using her own words
Demonstrate the procedure to the patient and encourage to ask questions
Ask the patient to demonstrate the procedure
33. Which of the following types of medications can be administered via gastrostomy tube?
Any oral medications
Capsules whole contents are dissolve in water
Enteric-coated tablets that are thoroughly dissolved in water
Most tablets designed for oral use, except for extended-duration compounds
34. A patient who develops hives after receiving an antibiotic is exhibiting drug:
Tolerance
Idiosyncrasy
Synergism
Allergy
35. A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:
Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
Check the pressure dressing for sanguineous drainage
Assess a vital signs every 15 minutes for 2 hours
Order a hemoglobin and hematocrit count 1 hour after the arteriography
36. The nurse explains to a patient that a cough:
Is a protective response to clear the respiratory tract of irritants
Is primarily a voluntary action
Is induced by the administration of an antitussive drug
Can be inhibited by “splinting” the abdomen
37. An infected patient has chills and begins shivering. The best nursing intervention is to:
Apply iced alcohol sponges
Provide increased cool liquids
Provide additional bedclothes
Provide increased ventilation
38. A clinical nurse specialist is a nurse who has:
Been certified by the National League for Nursing
Received credentials from the Philippine Nurses’ Association
Graduated from an associate degree program and is a registered professional nurse
Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
39. The purpose of increasing urine acidity through dietary means is to:
Decrease burning sensations
Change the urine’s color
Change the urine’s concentration
Inhibit the growth of microorganisms
40. Clay colored stools indicate:
Upper GI bleeding
Impending constipation
An effect of medication
Bile obstruction
41. In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
Assessment
Analysis
Planning
Evaluation
42. All of the following are good sources of vitamin A except:
White potatoes
Carrots
Apricots
Egg yolks
43. Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
Maintain the drainage tubing and collection bag level with the patient’s bladder
Irrigate the patient with 1% Neosporin solution three times a daily
Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
44. The ELISA test is used to:
Screen blood donors for antibodies to human immunodeficiency virus (HIV)
Test blood to be used for transfusion for HIV antibodies
Aid in diagnosing a patient with AIDS
All of the above
45. The two blood vessels most commonly used for TPN infusion are the:
Subclavian and jugular veins
Brachial and subclavian veins
Femoral and subclavian veins
Brachial and femoral veins
46. Effective skin disinfection before a surgical procedure includes which of the following methods?
Shaving the site on the day before surgery
Applying a topical antiseptic to the skin on the evening before surgery
Having the patient take a tub bath on the morning of surgery
Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery
47. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
Abdominal muscles
Back muscles
Leg muscles
Upper arm muscles
48. Thrombophlebitis typically develops in patients with which of the following conditions?
Increases partial thromboplastin time
Acute pulsus paradoxus
An impaired or traumatized blood vessel wall
Chronic Obstructive Pulmonary Disease (COPD)
49. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
Appneustic breathing, atypical pneumonia and respiratory alkalosis
Cheyne-Strokes respirations and spontaneous pneumothorax
Kussmail’s respirations and hypoventilation
50. Immobility impairs bladder elimination, resulting in such disorders as
Increased urine acidity and relaxation of the perineal muscles, causing incontinence
Urine retention, bladder distention, and infection
Diuresis, natriuresis, and decreased urine specific gravity
Decreased calcium and phosphate levels in the urine
Answers and Rationales
D. In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.
C. 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 desirable. The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation.
A. 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.
A. 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.
A. 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.
B. 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.
C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.
C. 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.
B. Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.
D. The inside of the glove is always considered to be clean, but not sterile.
A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.
B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.
B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.
A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 10,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.
A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.
A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.
A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.
D. The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.
D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.
A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).
D. A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
D. gr 10 x 60mg/gr 1 = 600 mg
C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia.
C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.
D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.
D. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.
D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects.
D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs.
C. In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
D. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.
D. Microorganisms usually do not grow in an acidic environment.
D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.
D. In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.
A. The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
D. Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
D. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
A. Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.
D. Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away.
C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.
C. The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.
A. Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
B. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.