Practice Mode– Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam.
Fundamentals of Nursing Practice Exam 4 (PM)
Choose the letter of the correct answer. Good luck!
Start
Congratulations - you have completed Fundamentals of Nursing Practice Exam 4 (PM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen?
A
Self esteem
B
Safety
C
Activity
D
Love
Question 1 Explanation:
According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen, shelter, food, water, erst, sleep and temperature maintenance.
Question 2
The nurse's main priority when caring for a patient with hemiplegia?
A
Helping the patient accept the illness
B
Providing a safe environment
C
Educating the patient
D
Promoting a positive self-image
Question 2 Explanation:
A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse's main priority.
Question 3
Constipation is a common problem for immobilized patients because of:
A
An increased defacation reflex
B
Decreased tightening of the anal sphincter
C
Decreased peristalsis and positional discomfort
D
Increased colon motility
Question 3 Explanation:
Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters.
Question 4
Which communication skills is most effective in dealing with covert communication?
A
Evaluation
B
Listening
C
Clarification
D
Validation
Question 4 Explanation:
Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer's perceptions through feedback, interpretation and clarification.
Question 5
Antiembolism stockings are used primarily to:
A
Prevent dependent edema
B
Promote venous circulation
C
Provide external warmth
D
Hold foot dressings
Question 5 Explanation:
Antiembolism stockings are elastic stockings designed to maintain compression of small veins and capillaries in the legs.
Question 6
Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus?
A
Sister Callista Roy
B
Martha Rogers
C
Dorothea Orem
D
Florence Nightingale
Question 6 Explanation:
Martha Roger's life process model views man as an evolving creature interacting with the environment in an open, adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his environment.
Question 7
An appropriate interdependent intervention to prevent thrombophebitis would be:
A
Encourage the patient to sit with his knees crossed
B
Apply antiembolism stockings to both legs.
C
Massage the legs vigorously
D
Elevate the knee gatch of the bed
Question 7 Explanation:
Antiembolism stockings increase venous return to the heart, which helps prevent thromboplebitis.
Question 8
Which of the following may be considered a patient's right?
A
The right to refuse to pay for what the patient considers to be inferior service.
B
The right to refuse treatment
C
The right to ignore hospital regulations
D
The right to euthanasia
Question 8 Explanation:
Under the bill of rights law, the patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be informed of the medical consequences of his action.
Question 9
Which of the following nursing theorists developed a conceptual model based on the belief that all persons strive to achieve self-care?
A
Dorothea Orem
B
Cister Callista Roy
C
Martha Rogers
D
Florence Nightingale
Question 9 Explanation:
Dorothea Orem's conceptual model is based on the premise that all persons need to achieve self-care. She also views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.
Question 10
Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by:
A
Partial rebreathing mask
B
Nasal catheter
C
Nasal Cannula
D
Croupette
Question 10 Explanation:
The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.
Question 11
Which of the following questions is most appropriate to ask when interviewing a potential candidate for an RN position?
A
Are you willing to do overtime on weekends?
B
Do you plan to get pregnant?
C
What was your last nursing experience?
D
How many children do you have?
Question 11 Explanation:
An interviewer's question should center on the applicant's qualifications for the position. Questions about the applicant's personal life are inappropriate and may be illegal.
Question 12
A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action?
A
Administer a sedative at bedtime, as ordered by the physician
B
Close the patient's door from 9pm to 7am
C
Ambulate the patient for 5 minutes before he retires
D
Give the patient a glass of warm milk before bedtime
Question 12 Explanation:
Warm milk will relax the patient because it contains tryptophan, a natural sedative.
Question 13
The average daily amount of urine excreted by an adult is:
A
1,500 to 2,000 ml
B
1,000 to 1,200 ml
C
800 to 1,400 ml
D
500 to 600 ml
Question 13 Explanation:
An adult's average urine output ranges between 1,500 and 2,000 ml/day.
Question 14
The usual sequence for assessing the bowel is:
A
Rectum, pancreas, stomach and liver
B
Right lower lobe, right upper lobe, left upper lobe, left lower lobe
C
Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
D
Right hypochondriac, left hypochondriac and umbilical regions
Question 14 Explanation:
This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and the umbilical area are three of the nine regions of the abdomen.
Question 15
The term gavage indicates:
A
Visual examination of the stomach
B
Administration of a liquid feeding into the stomach
C
A surgical opening through the abdomen to the stomach
D
Irrigation of the stomach with a solution
Question 15 Explanation:
Gavage is the administration of a liquid feeding into the stomach
Question 16
S1 is heard best at the:
A
Second left intercoastal space at the sternal border
B
3rd intercoastal space to the left of the midclavicular line
C
Second right intercoastal space at the sternal border
D
5th left intercoastal space along the midclavicular line
Question 16 Explanation:
The S1 heart sound is best heard at the apex of the heart, at the fifth intercoastal space along the midclavicular line. (An infant's apex is located at the third or fourth intercoastal space just to the left of the midclavicular line)
Question 17
Blood pressure measurement is an important part of the patient's data base. It is considered to be:
A
Subjective data
B
The basis of the nursing diagnosis
C
Objective data
D
An indicator of the patient's well being
Question 17 Explanation:
Objective data are those such as BP, which can be measured or perceived by someone other than the patient. Subjective data are those such as pain, which only the patient can perceive.
Question 18
To promote correct anatomic alignment in a supine patient, the nurse should:
A
Place a pillow under the patient's knees
B
Place the patient's feet in dorsiflexion
C
Hyperextend the patient's neck
D
Adduct the patient's shoulder
Question 18 Explanation:
Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs)
Question 19
If a patient sues a nurse for malpractice, the patient must be able to prove:
A
Error, injury and proximal cause
B
Proximal cause, negligence and nurse error
C
Error, proximal cause, and lack of concern
D
Injury, error and assault
Question 19 Explanation:
Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two.
Question 20
Postural drainage to relieve respiratory congestion should take place:
A
After meals
B
Before meals
C
At the patient's convenience
D
At the nurse's convenience
Question 20 Explanation:
Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The patient's safety supersedes the convenience in scheduling this procedure.
Question 21
The correct site at which to verify a radial pulse measurement is the:
A
Temporal artery
B
Inguinal site
C
Brachial artery
D
Apex of the heart
Question 21 Explanation:
The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.
Question 22
If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the nurse?
A
The nursing supervisor
B
All of the above
C
The hospital
D
The private attending physician
Question 22 Explanation:
Under the master servant rule (also known as the doctrine or respondeat superior), when a person is injured by an employee as a result of negligence in the course of the employee's work, the employer is responsible to the injured person.
Question 23
A sudden redness of the skin is known as:
A
Pallor
B
Cyanosis
C
Jaundice
D
Flush
Question 23 Explanation:
Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclerae caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.
Question 24
The nurse should take a rectal temperature of a patient who has:
A
Nasal packing
B
His arm in a cast
C
External hemorrhoids
D
Gastrostomy feeding tubes
Question 24 Explanation:
A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and those who have history of seizures, etc). However, a rectal temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea)
Question 25
Which of the following qualities are relevant in documenting patient care?
A
Accuracy and conciseness
B
Thoroughness and currentness
C
Organization
D
All of the above
Question 25 Explanation:
Documentation should leave no room for misinterpretation. Thus, the nurse must ensure that all information pertinent to patient care is reworded accurately, concisely and thoroughly. The information must be up-to-date and well organized.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results
There are 25 questions to complete.
←
List
→
Return
Shaded items are complete.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
End
Return
You have completed
questions
question
Your score is
Correct
Wrong
Partial-Credit
You have not finished your quiz. If you leave this page, your progress will be lost.
Correct Answer
You Selected
Not Attempted
Final Score on Quiz
Attempted Questions Correct
Attempted Questions Wrong
Questions Not Attempted
Total Questions on Quiz
Question Details
Results
Date
Score
Hint
Time allowed
minutes
seconds
Time used
Answer Choice(s) Selected
Question Text
All done
Need more practice!
Keep trying!
Not bad!
Good work!
Perfect!
Exam Mode
Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
Fundamentals of Nursing Practice Exam 4 (EM)
Choose the letter of the correct answer. You got 25 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed Fundamentals of Nursing Practice Exam 4 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
The nurse should take a rectal temperature of a patient who has:
A
Gastrostomy feeding tubes
B
External hemorrhoids
C
Nasal packing
D
His arm in a cast
Question 1 Explanation:
A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and those who have history of seizures, etc). However, a rectal temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea)
Question 2
The average daily amount of urine excreted by an adult is:
A
1,000 to 1,200 ml
B
1,500 to 2,000 ml
C
500 to 600 ml
D
800 to 1,400 ml
Question 2 Explanation:
An adult's average urine output ranges between 1,500 and 2,000 ml/day.
Question 3
The usual sequence for assessing the bowel is:
A
Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
B
Rectum, pancreas, stomach and liver
C
Right lower lobe, right upper lobe, left upper lobe, left lower lobe
D
Right hypochondriac, left hypochondriac and umbilical regions
Question 3 Explanation:
This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and the umbilical area are three of the nine regions of the abdomen.
Question 4
Postural drainage to relieve respiratory congestion should take place:
A
At the nurse's convenience
B
After meals
C
At the patient's convenience
D
Before meals
Question 4 Explanation:
Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The patient's safety supersedes the convenience in scheduling this procedure.
Question 5
The term gavage indicates:
A
Administration of a liquid feeding into the stomach
B
Visual examination of the stomach
C
A surgical opening through the abdomen to the stomach
D
Irrigation of the stomach with a solution
Question 5 Explanation:
Gavage is the administration of a liquid feeding into the stomach
Question 6
Constipation is a common problem for immobilized patients because of:
A
An increased defacation reflex
B
Increased colon motility
C
Decreased tightening of the anal sphincter
D
Decreased peristalsis and positional discomfort
Question 6 Explanation:
Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters.
Question 7
S1 is heard best at the:
A
5th left intercoastal space along the midclavicular line
B
Second right intercoastal space at the sternal border
C
Second left intercoastal space at the sternal border
D
3rd intercoastal space to the left of the midclavicular line
Question 7 Explanation:
The S1 heart sound is best heard at the apex of the heart, at the fifth intercoastal space along the midclavicular line. (An infant's apex is located at the third or fourth intercoastal space just to the left of the midclavicular line)
Question 8
A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action?
A
Ambulate the patient for 5 minutes before he retires
B
Give the patient a glass of warm milk before bedtime
C
Close the patient's door from 9pm to 7am
D
Administer a sedative at bedtime, as ordered by the physician
Question 8 Explanation:
Warm milk will relax the patient because it contains tryptophan, a natural sedative.
Question 9
Which of the following nursing theorists developed a conceptual model based on the belief that all persons strive to achieve self-care?
A
Dorothea Orem
B
Cister Callista Roy
C
Martha Rogers
D
Florence Nightingale
Question 9 Explanation:
Dorothea Orem's conceptual model is based on the premise that all persons need to achieve self-care. She also views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.
Question 10
If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the nurse?
A
The hospital
B
The private attending physician
C
The nursing supervisor
D
All of the above
Question 10 Explanation:
Under the master servant rule (also known as the doctrine or respondeat superior), when a person is injured by an employee as a result of negligence in the course of the employee's work, the employer is responsible to the injured person.
Question 11
Antiembolism stockings are used primarily to:
A
Promote venous circulation
B
Hold foot dressings
C
Prevent dependent edema
D
Provide external warmth
Question 11 Explanation:
Antiembolism stockings are elastic stockings designed to maintain compression of small veins and capillaries in the legs.
Question 12
Which of the following qualities are relevant in documenting patient care?
A
Accuracy and conciseness
B
Organization
C
Thoroughness and currentness
D
All of the above
Question 12 Explanation:
Documentation should leave no room for misinterpretation. Thus, the nurse must ensure that all information pertinent to patient care is reworded accurately, concisely and thoroughly. The information must be up-to-date and well organized.
Question 13
An appropriate interdependent intervention to prevent thrombophebitis would be:
A
Apply antiembolism stockings to both legs.
B
Encourage the patient to sit with his knees crossed
C
Massage the legs vigorously
D
Elevate the knee gatch of the bed
Question 13 Explanation:
Antiembolism stockings increase venous return to the heart, which helps prevent thromboplebitis.
Question 14
According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen?
A
Activity
B
Safety
C
Self esteem
D
Love
Question 14 Explanation:
According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen, shelter, food, water, erst, sleep and temperature maintenance.
Question 15
To promote correct anatomic alignment in a supine patient, the nurse should:
A
Hyperextend the patient's neck
B
Place a pillow under the patient's knees
C
Place the patient's feet in dorsiflexion
D
Adduct the patient's shoulder
Question 15 Explanation:
Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs)
Question 16
Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by:
A
Partial rebreathing mask
B
Nasal Cannula
C
Croupette
D
Nasal catheter
Question 16 Explanation:
The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.
Question 17
A sudden redness of the skin is known as:
A
Pallor
B
Cyanosis
C
Jaundice
D
Flush
Question 17 Explanation:
Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclerae caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.
Question 18
If a patient sues a nurse for malpractice, the patient must be able to prove:
A
Error, proximal cause, and lack of concern
B
Error, injury and proximal cause
C
Injury, error and assault
D
Proximal cause, negligence and nurse error
Question 18 Explanation:
Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two.
Question 19
Which communication skills is most effective in dealing with covert communication?
A
Validation
B
Clarification
C
Listening
D
Evaluation
Question 19 Explanation:
Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer's perceptions through feedback, interpretation and clarification.
Question 20
Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus?
A
Sister Callista Roy
B
Dorothea Orem
C
Martha Rogers
D
Florence Nightingale
Question 20 Explanation:
Martha Roger's life process model views man as an evolving creature interacting with the environment in an open, adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his environment.
Question 21
Blood pressure measurement is an important part of the patient's data base. It is considered to be:
A
The basis of the nursing diagnosis
B
Objective data
C
Subjective data
D
An indicator of the patient's well being
Question 21 Explanation:
Objective data are those such as BP, which can be measured or perceived by someone other than the patient. Subjective data are those such as pain, which only the patient can perceive.
Question 22
The nurse's main priority when caring for a patient with hemiplegia?
A
Promoting a positive self-image
B
Helping the patient accept the illness
C
Providing a safe environment
D
Educating the patient
Question 22 Explanation:
A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse's main priority.
Question 23
The correct site at which to verify a radial pulse measurement is the:
A
Temporal artery
B
Inguinal site
C
Brachial artery
D
Apex of the heart
Question 23 Explanation:
The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.
Question 24
Which of the following questions is most appropriate to ask when interviewing a potential candidate for an RN position?
A
What was your last nursing experience?
B
How many children do you have?
C
Are you willing to do overtime on weekends?
D
Do you plan to get pregnant?
Question 24 Explanation:
An interviewer's question should center on the applicant's qualifications for the position. Questions about the applicant's personal life are inappropriate and may be illegal.
Question 25
Which of the following may be considered a patient's right?
A
The right to refuse to pay for what the patient considers to be inferior service.
B
The right to euthanasia
C
The right to refuse treatment
D
The right to ignore hospital regulations
Question 25 Explanation:
Under the bill of rights law, the patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be informed of the medical consequences of his action.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results
There are 25 questions to complete.
←
List
→
Return
Shaded items are complete.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
End
Return
You have completed
questions
question
Your score is
Correct
Wrong
Partial-Credit
You have not finished your quiz. If you leave this page, your progress will be lost.
Correct Answer
You Selected
Not Attempted
Final Score on Quiz
Attempted Questions Correct
Attempted Questions Wrong
Questions Not Attempted
Total Questions on Quiz
Question Details
Results
Date
Score
Hint
Time allowed
minutes
seconds
Time used
Answer Choice(s) Selected
Question Text
All done
Need more practice!
Keep trying!
Not bad!
Good work!
Perfect!
Text Mode
Text Mode – Text version of the exam
1. A sudden redness of the skin is known as:
Flush
Cyanosis
Jaundice
Pallor
2. The term gavage indicates:
Administration of a liquid feeding into the stomach
Visual examination of the stomach
Irrigation of the stomach with a solution
A surgical opening through the abdomen to the stomach
3. A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action?
Administer a sedative at bedtime, as ordered by the physician
Ambulate the patient for 5 minutes before he retires
Give the patient a glass of warm milk before bedtime
Close the patient’s door from 9pm to 7am
4. Which of the following nursing theorists dveloped a conceptual model based on the belief that all persons strive to achieve self-care?
Martha Rogers
Dorothea Orem
Florence Nightingale
Cister Callista Roy
5. Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus?
Martha Rogers
Dorothea Orem
Florence Nightingale
Sister Callista Roy
6. Which of the following questions is most appropriate to ask when interviewing a potential candidate fo an RN position?
What was your last nursing experience?
Are you willing to do overtime on weekends?
How many children do you have?
Do you plan to get pregnant?
7. If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the nurse?
The private attending physician
The nursing supervisor
The hospital
All of the above
8. Which of the following may be considered a patient’s right?
The right to euthanasia
The right to refuse treatment
The right to ignore hospital regulations
The right to refuse to pay for what the patient considers to be inferior service.
9. If a patient sues a nurse for malpractice, the patient must be able to prove:
Error, proximal cause, and lack of concern
Error, injury and proximal cause
Injury, error and assault
Proximal cause, negligence and nurse error
10. Which communication skills is most effective in dealing with covert communication?
Validation
Listening
Evaluation
Clarification
11. Which of the following qualities are relevant in documenting patient care?
Accuracy and conciseness
Thoroughness and currentness
Organization
All of the above
12. The usual sequence for assessing the bowel is:
Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
Right lower lobe, right upper lobe, left upper lobe, left lower lobe
Right hypochondriac, left hypochondriac and umbilical regions
Rectum, pancreas, stomach and liver
13. The nurse should take a rectal temperature of a patient who has:
His arm in a cast
Nasal packing
External hemorrhoids
Gastrostomy feeding tubes
14. Blood pressure measurement is an important part of the patient’s data base. It is considered to be:
The basis of the nursing diagnosis
Objective data
An indicator of the patient’s well being
Subjective data
15. Postural drainage to relieve respiratory congestion should take place:
Before meals
After meals
At the nurse’s convenience
At the patient’s convenience
16. The correct site at which to verify a radial pulse measurement is the:
Brachial artery
Apex of the heart
Temporal artery
Inguinal site
17. S1 is heard best at the:
5th left intercoastal space along the midclavicular line
3rd intercoastal space to the left of the midclavicular line
Second right intercoastal space at the sternal border
Second left intercoastal space at the sternal border
18. The nurse’s main priority when caring foar a patient with hemiplegia?
Educating the patient
Providing a safe environment
Promoting a positive self-image
Helping the patient accept the illness
19. Constipation is a common problem for immobilized patients because of:
Decreased peristalsis and positional discomfort
An increased defacation reflex
Decreased tightening of the anal sphincter
Increased colon motility
20. Antiembolism stockings are used primarily to:
Promote venous circulation
Provide external warmth
Prevent dependent edema
Hold foot dressings
21. To promote correct anatomic alignment in a supine patient, the nurse should:
Place the patient’s feet in dorsiflexion
Place a pillow under the patient’s knees
Hyperextend the patient’s neck
Adduct the patient’s shoulder
22. An appropriate interdependent intervention to prevent thrombophebitis would be:
Elevate the knee gatch of the bed
Massage the legs vigorously
Apply antiembolism stockings to both legs.
Encourage the patient to sit with his knees crossed
23. The average daily amount of urine excreted by an adult is:
500 to 600 ml
800 to 1,400 ml
1,000 to 1,200 ml
1,500 to 2,000 ml
24. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after oxygen?
Activity
Safety
Love
Self esteem
25. Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by:
Croupette
Nasal Cannula
Nasal catheter
Partial rebreathing mask
Answers and Rationales
Answer : (A) Flush. Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclerae caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.
Answer :(A) Administration of a liquid feeding into the stomach. Gavage is the administration of a liquid feeding into the stomach
Answer :(C) Give the patient a glass of warm milk before bedtime. Warm milk will relax the patient because it contains tryptophan, a natural sedative.
Answer :(B) Dorothea Orem. Dorothea Orem’s conceptual model is based on the premise that all persons need to achieve self-care. She also views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.
Answer :(A) Martha Rogers. Martha Roger’s life process model views man as an evolving creature interacting with the environment in an open, adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his environment.
Answer :(A) What was your last nursing experience?. An interviewer’s question should center on the applicant’s qualifications for the position. Questions about the applicant’s personal life are inappropriate and may be illegal.
Answer :(C) The hospital. Under the master servant rule (also known as the doctrine or respondeat superior), when a person is injured by an employee as a result of negligence in the course of the employee’s work, the employer is responsible to the injured person.
Answer :(B) The right to refuse treatment. Under the bill of rights law, the patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be informed of the medical consequences of his action.
Answer :(B) Error, injury and proximal cause. Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two.
Answer :(A) Validation. Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer’s perceptions through feedback, interpretation and clarification.
Answer :(D) All of the above. Documentation should leave no room for misinterpretation. Thus, the nurse must ensure that all information pertinent to patient care is reworded accurately, concisely and thoroughly. The information must be up-to-date and well organized.
Answer :(A) Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant. This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and the umbilical area are three of the nine regions of the abdomen.
Answer :(B) Nasal packing. A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and those who have history of seizures, etc). However, a rectal temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea)
Answer :(B) Objective data. Objective data are those such as BP, which can be measured or perceived by someone other than the patient. Subjective data are those such as pain, which only the patient can perceive.
Answer :(A) Before meals. Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The patient’s safety supersedes the convenience in scheduling this procedure.
Answer :(B) Apex of the heart. The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.
Answer :(A) 5th left intercoastal space along the midclavicular line. The S1 heart sound is best heard at the apex of the heart, at the fifth intercoastal space along the midclavicular line. (An infant’s apex is located at the third or fourth intercoastal space just to the left of the midclavicular line)
Answer :(B) Providing a safe environment. A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse’s main priority.
Answer :(A) Decreased peristalsis and positional discomfort. Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters.
Answer :(A) Promote venous circulation. Antiembolism stockings are elastic stockings designed to maintain compression of small veins and capillaries in the legs.
Answer :(A) Place the patient’s feet in dorsiflexion. Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs)
Answer :(C) Apply antiembolism stockings to both legs.. Antiembolism stockings increase venous return to the heart, which helps prevent thromboplebitis.
Answer :(D) 1,500 to 2,000 ml. An adult’s average urine output ranges between 1,500 and 2,000 ml/day.
Answer :(A) Activity. According to Maslow, activity is one of the man’s most basic physiologic needs, along with oxygen, shelter, food, water, erst, sleep and temperature maintenance.
Answer :(B) Nasal Cannula. The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.