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PNLE: Fundamentals in Nursing Exam 1 (PM)
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Question 1
Which of the following is inappropriate nursing action when administering NGT feeding?
A
Instill 60ml of water into the NGT after feeding.
B
Introduce the feeding slowly.
C
Place the feeding 20 inches above the pint if insertion of NGT.
D
Assist the patient in fowler’s position.
Question 1 Explanation:
The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.
Question 2
A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A
Manager
B
Educator
C
Patient advocate
D
Caregiver
Question 2 Explanation:
When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patient’s wishes known to the doctor.
Question 3
Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia?
A
Capillary refill greater than 3 seconds and buccal cyanosis
B
Hemoglobin of 13 g/dl
C
Clear breath sounds
D
Oriented to date, time and place
Question 3 Explanation:
Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data.
Question 4
During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient?
A
That the patient verbalized, “My headache is gone.”
B
Patient’s NGT was removed 2 hours ago
C
That the patient’s barium enema performed 3 days ago was negative
D
Patient’s family came for a visit this morning.
Question 4 Explanation:
The change-of-shift report should indicate significant recent changes in the patient’s condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report.
Question 5
Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?
A
Anxiety related to impending surgery, as evidenced by insomnia.
B
Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
C
Risk of injury related to autoimmune dysfunction
D
Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.
Question 5 Explanation:
Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority.
Question 6
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
A
Disconnect the catheter from the tubing and get urine.
B
Open the drainage bag and pour out the urine.
C
Aspirate urine from the tubing port using a sterile syringe.
D
Use sterile gloves when obtaining urine.
Question 6 Explanation:
The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.
The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
Question 8
Which expected outcome is correctly written?
A
“The patient will eat the right amount of food daily.”
B
“The patient will feel less nauseated in 24 hours.”
C
“The patient will identify all the high-salt food from a prepared list by discharge.”
D
“The patient will have enough sleep.”
Question 8 Explanation:
Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are vague and not measurable.
Question 9
Which of the following is the most important purpose of planning care with this patient?
A
Development of a standardized NCP.
B
Expansion of the current taxonomy of nursing diagnosis
C
Incorporation of both nursing and medical diagnoses in patient care
D
Making of individualized patient care
Question 9 Explanation:
To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.
Question 10
When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position?
A
0 degree
B
45 degrees
C
30 degrees
D
90 degrees
Question 10 Explanation:
The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings
Question 11
Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?
A
“The patient will take anti-diarrheal medication.”
B
“The patient will give a stool specimen for laboratory examinations.”
C
“The patient will experience decreased frequency of bowel elimination.”
D
“The patient will save urine for inspection by the nurse.
Question 11 Explanation:
The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.
Question 12
The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
A
After few minutes, return to that patient’s room and do not leave until the patient takes the medication.
B
Leave the medication at the bedside and leave the room.
C
Instruct the patient to take the medication and leave it at the bedside.
D
Wait for the patient to return to bed and just leave the medication at the bedside.
Question 12 Explanation:
This is to verify or to make sure that the medication was taken by the patient as directed.
Question 13
During the planning phase of the nursing process, which of the following is the outcome?
A
Nursing history
B
Nursing care plan
C
Nursing notes
D
Nursing diagnosis
Question 13 Explanation:
The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.
Question 14
The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:
A
Wheezes
B
Gurgles
C
Vesicular
D
Rhonchi
Question 14 Explanation:
Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration.
Question 15
Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as:
A
Cultural belief
B
Health belief
C
Superstitious belief
D
Personal belief
Question 15 Explanation:
Health belief of an individual influences his/her preventive health behavior.
Question 16
A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first?
A
Place a clod towel on the site
B
Slow that infusion to 20 ml/hr
C
Call the attending physician
D
Stop the infusion
Question 16 Explanation:
The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.
Question 17
The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature?
A
37.95 degrees C
B
38.01 degrees C
C
40.03 degrees C
D
36.3 degrees C
Question 17 Explanation:
To convert °F to °C use this formula, ( °F – 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.
Question 18
What is the disadvantage of computerized documentation of the nursing process?
A
Legibility
B
Concern for privacy
C
Rapid communication
D
Accuracy
Question 18 Explanation:
A patient’s privacy may be violated if security measures aren’t used properly or if policies and procedures aren’t in place that determines what type of information can be retrieved, by whom, and for what purpose.
Question 19
What is an example of a subjective data?
A
Yellowish sputum
B
Heart rate of 68 beats per minute
C
Client verbalized, “I feel pain when urinating.”
D
Noisy breathing
Question 19 Explanation:
Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not.
Question 20
Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response?
A
Decreased urine output
B
Decreased serum sodium levels
C
Low blood pressure
D
Warm, dry skin
Question 20 Explanation:
Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.
Question 21
The theorist who believes that adaptation and manipulation of stressors are related to foster change is:
A
Sister Callista Roy
B
Virginia Henderson
C
Dorothea Orem
D
Imogene King
Question 21 Explanation:
Sister Roy’s theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. King’s theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs.
Question 22
Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?
A
Scientific method
B
Routine
C
Intuition
D
Trial and error
Question 22 Explanation:
The trial and error method of problem solving isn’t systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving).
Question 23
Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting?
A
She signs on the medication sheet after administering the medication.
B
She noted: appetite is good this afternoon.
C
She signs her charting as follow: J.R
D
She writes in the chart using a no. 2 pencil.
Question 23 Explanation:
A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurse’s full name and title.
Question 24
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
A
Respiratory rate greater than 20 breaths per minute
B
Pulse rate greater than 100 beats per minute
C
Blood pressure of 140/90
D
Frequent bowel sounds
Question 24 Explanation:
A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.
Question 25
Formulating a nursing diagnosis is a joint function of:
A
Patient and relatives
B
Nurse and doctor
C
Doctor and family
D
Nurse and patient
Question 25 Explanation:
Although diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.
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PNLE: Fundamentals in Nursing Exam 1 (EM)
Choose the letter of the correct answer. You got 25 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed PNLE: Fundamentals in Nursing Exam 1 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature?
A
38.01 degrees C
B
37.95 degrees C
C
40.03 degrees C
D
36.3 degrees C
Question 1 Explanation:
To convert °F to °C use this formula, ( °F – 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.
Question 2
Which expected outcome is correctly written?
A
“The patient will identify all the high-salt food from a prepared list by discharge.”
B
“The patient will feel less nauseated in 24 hours.”
C
“The patient will eat the right amount of food daily.”
D
“The patient will have enough sleep.”
Question 2 Explanation:
Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are vague and not measurable.
Question 3
Formulating a nursing diagnosis is a joint function of:
A
Nurse and doctor
B
Doctor and family
C
Patient and relatives
D
Nurse and patient
Question 3 Explanation:
Although diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.
Question 4
When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position?
A
90 degrees
B
45 degrees
C
30 degrees
D
0 degree
Question 4 Explanation:
The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings
Question 5
The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
A
After few minutes, return to that patient’s room and do not leave until the patient takes the medication.
B
Instruct the patient to take the medication and leave it at the bedside.
C
Wait for the patient to return to bed and just leave the medication at the bedside.
D
Leave the medication at the bedside and leave the room.
Question 5 Explanation:
This is to verify or to make sure that the medication was taken by the patient as directed.
Question 6
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
A
Respiratory rate greater than 20 breaths per minute
B
Pulse rate greater than 100 beats per minute
C
Frequent bowel sounds
D
Blood pressure of 140/90
Question 6 Explanation:
A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.
Question 7
The theorist who believes that adaptation and manipulation of stressors are related to foster change is:
A
Imogene King
B
Dorothea Orem
C
Sister Callista Roy
D
Virginia Henderson
Question 7 Explanation:
Sister Roy’s theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. King’s theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs.
Question 8
Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting?
A
She signs on the medication sheet after administering the medication.
B
She noted: appetite is good this afternoon.
C
She signs her charting as follow: J.R
D
She writes in the chart using a no. 2 pencil.
Question 8 Explanation:
A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurse’s full name and title.
Question 9
What is an example of a subjective data?
A
Yellowish sputum
B
Client verbalized, “I feel pain when urinating.”
C
Noisy breathing
D
Heart rate of 68 beats per minute
Question 9 Explanation:
Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not.
Question 10
Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?
A
“The patient will give a stool specimen for laboratory examinations.”
B
“The patient will take anti-diarrheal medication.”
C
“The patient will experience decreased frequency of bowel elimination.”
D
“The patient will save urine for inspection by the nurse.
Question 10 Explanation:
The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.
Question 11
Which of the following is the most important purpose of planning care with this patient?
A
Expansion of the current taxonomy of nursing diagnosis
B
Making of individualized patient care
C
Incorporation of both nursing and medical diagnoses in patient care
D
Development of a standardized NCP.
Question 11 Explanation:
To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.
Question 12
What is the disadvantage of computerized documentation of the nursing process?
A
Rapid communication
B
Accuracy
C
Concern for privacy
D
Legibility
Question 12 Explanation:
A patient’s privacy may be violated if security measures aren’t used properly or if policies and procedures aren’t in place that determines what type of information can be retrieved, by whom, and for what purpose.
The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
Question 14
During the planning phase of the nursing process, which of the following is the outcome?
A
Nursing diagnosis
B
Nursing care plan
C
Nursing history
D
Nursing notes
Question 14 Explanation:
The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.
Question 15
Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as:
A
Health belief
B
Superstitious belief
C
Personal belief
D
Cultural belief
Question 15 Explanation:
Health belief of an individual influences his/her preventive health behavior.
Question 16
A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first?
A
Slow that infusion to 20 ml/hr
B
Place a clod towel on the site
C
Stop the infusion
D
Call the attending physician
Question 16 Explanation:
The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.
Question 17
A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A
Educator
B
Patient advocate
C
Manager
D
Caregiver
Question 17 Explanation:
When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patient’s wishes known to the doctor.
Question 18
Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response?
A
Low blood pressure
B
Decreased serum sodium levels
C
Warm, dry skin
D
Decreased urine output
Question 18 Explanation:
Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.
Question 19
The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:
A
Vesicular
B
Gurgles
C
Rhonchi
D
Wheezes
Question 19 Explanation:
Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration.
Question 20
Which of the following is inappropriate nursing action when administering NGT feeding?
A
Place the feeding 20 inches above the pint if insertion of NGT.
B
Assist the patient in fowler’s position.
C
Introduce the feeding slowly.
D
Instill 60ml of water into the NGT after feeding.
Question 20 Explanation:
The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.
Question 21
Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?
A
Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
B
Anxiety related to impending surgery, as evidenced by insomnia.
C
Risk of injury related to autoimmune dysfunction
D
Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.
Question 21 Explanation:
Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority.
Question 22
During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient?
A
Patient’s NGT was removed 2 hours ago
B
That the patient’s barium enema performed 3 days ago was negative
C
That the patient verbalized, “My headache is gone.”
D
Patient’s family came for a visit this morning.
Question 22 Explanation:
The change-of-shift report should indicate significant recent changes in the patient’s condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report.
Question 23
Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?
A
Intuition
B
Scientific method
C
Routine
D
Trial and error
Question 23 Explanation:
The trial and error method of problem solving isn’t systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving).
Question 24
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
A
Aspirate urine from the tubing port using a sterile syringe.
B
Open the drainage bag and pour out the urine.
C
Disconnect the catheter from the tubing and get urine.
D
Use sterile gloves when obtaining urine.
Question 24 Explanation:
The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.
Question 25
Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia?
A
Oriented to date, time and place
B
Hemoglobin of 13 g/dl
C
Capillary refill greater than 3 seconds and buccal cyanosis
D
Clear breath sounds
Question 25 Explanation:
Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data.
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1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
Pulse rate greater than 100 beats per minute
Blood pressure of 140/90
Respiratory rate greater than 20 breaths per minute
Frequent bowel sounds
2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:
Wheezes
Rhonchi
Gurgles
Vesicular
3. The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature?
36.3 degrees C
37.95 degrees C
40.03 degrees C
38.01 degrees C
4. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?
6. During the planning phase of the nursing process, which of the following is the outcome?
Nursing history
Nursing notes
Nursing care plan
Nursing diagnosis
7. What is an example of a subjective data?
Heart rate of 68 beats per minute
Yellowish sputum
Client verbalized, “I feel pain when urinating.”
Noisy breathing
8. Which expected outcome is correctly written?
“The patient will feel less nauseated in 24 hours.”
“The patient will eat the right amount of food daily.”
“The patient will identify all the high-salt food from a prepared list by discharge.”
“The patient will have enough sleep.”
9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th elements of effecting charting?
She writes in the chart using a no. 2 pencil.
She noted: appetite is good this afternoon.
She signs on the medication sheet after administering the medication.
She signs her charting as follow: J.R
10. What is the disadvantage of computerized documentation of the nursing process?
Accuracy
Legibility
Concern for privacy
Rapid communication
11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is:
Dorothea Orem
Sister Callista Roy
Imogene King
Virginia Henderson
12. Formulating a nursing diagnosis is a joint function of:
Patient and relatives
Nurse and patient
Doctor and family
Nurse and doctor
13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as:
Cultural belief
Personal belief
Health belief
Superstitious belief
14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response?
Low blood pressure
Warm, dry skin
Decreased serum sodium levels
Decreased urine output
15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
Use sterile gloves when obtaining urine.
Open the drainage bag and pour out the urine.
Disconnect the catheter from the tubing and get urine.
Aspirate urine from the tubing port using a sterile syringe.
16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first?
Stop the infusion
Call the attending physician
Slow that infusion to 20 ml/hr
Place a clod towel on the site
17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
Leave the medication at the bedside and leave the room.
After few minutes, return to that patient’s room and do not leave until the patient takes the medication.
Instruct the patient to take the medication and leave it at the bedside.
Wait for the patient to return to bed and just leave the medication at the bedside.
18. Which of the following is inappropriate nursing action when administering NGT feeding?
Place the feeding 20 inches above the pint if insertion of NGT.
Introduce the feeding slowly.
Instill 60ml of water into the NGT after feeding.
Assist the patient in fowler’s position.
19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
Manager
Caregiver
Patient advocate
Educator
20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia?
Oriented to date, time and place
Clear breath sounds
Capillary refill greater than 3 seconds and buccal cyanosis
Hemoglobin of 13 g/dl
21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient?
That the patient verbalized, “My headache is gone.”
That the patient’s barium enema performed 3 days ago was negative
Patient’s NGT was removed 2 hours ago
Patient’s family came for a visit this morning.
22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?
“The patient will experience decreased frequency of bowel elimination.”
“The patient will take anti-diarrheal medication.”
“The patient will give a stool specimen for laboratory examinations.”
“The patient will save urine for inspection by the nurse.
23. Which of the following is the most important purpose of planning care with this patient?
Development of a standardized NCP.
Expansion of the current taxonomy of nursing diagnosis
Making of individualized patient care
Incorporation of both nursing and medical diagnoses in patient care
24. Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?
Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
Anxiety related to impending surgery, as evidenced by insomnia.
Risk of injury related to autoimmune dysfunction
Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.
25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position?
30 degrees
90 degrees
45 degrees
0 degree
Answers and Rationales
1. (C) Respiratory rate greater than 20 breaths per minute. A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.
(A) Wheezes. Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration.
(B) 37.95 degrees C. To convert °F to °C use this formula, ( °F – 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.
(D) Trial and error. The trial and error method of problem solving isn’t systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving).
(C) Assessing, diagnosing, planning, implementing, evaluating. The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
(C) Nursing care plan. The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.
(C) Client verbalized, “I feel pain when urinating.”. Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not.
(C) “The patient will identify all the high-salt food from a prepared list by discharge.”. Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are vague and not measurable.
(C) She signs on the medication sheet after administering the medication.A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurse’s full name and title.
(C) Concern for privacy. A patient’s privacy may be violated if security measures aren’t used properly or if policies and procedures aren’t in place that determines what type of information can be retrieved, by whom, and for what purpose.
(B) Sister Callista Roy. Sister Roy’s theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. King’s theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs.
(B) Nurse and patient. Although diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.
(C) Health belief. Health belief of an individual influences his/her preventive health behavior.
(D) Decreased urine output. Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.
(D) Aspirate urine from the tubing port using a sterile syringe. The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.
(A) Stop the infusion. The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.
(B) After few minutes, return to that patient’s room and do not leave until the patient takes the medication. This is to verify or to make sure that the medication was taken by the patient as directed.
(A) Place the feeding 20 inches above the pint if insertion of NGT. The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.
(D) Educator. When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patient’s wishes known to the doctor.
(C) Capillary refill greater than 3 seconds and buccal cyanosis. Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data.
(C) Patient’s NGT was removed 2 hours ago. The change-of-shift report should indicate significant recent changes in the patient’s condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report.
(A) “The patient will experience decreased frequency of bowel elimination.” The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.
(C) Making of individualized patient care. To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.
(A) Ineffective breathing pattern related to pain, as evidenced by shortness of breath.. Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority.
(D) 0 degree. The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings