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PNLE: Fundamentals in Nursing Exam 1 (PM)
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Question 1
The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:
A
Wheezes
B
Vesicular
C
Rhonchi
D
Gurgles
Question 1 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 2
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
30 degrees
C
45 degrees
D
90 degrees
Question 2 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 3
What is the disadvantage of computerized documentation of the nursing process?
A
Legibility
B
Rapid communication
C
Concern for privacy
D
Accuracy
Question 3 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 4
What is an example of a subjective data?
A
Yellowish sputum
B
Noisy breathing
C
Heart rate of 68 beats per minute
D
Client verbalized, “I feel pain when urinating.”
Question 4 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 5
Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?
A
Intuition
B
Trial and error
C
Routine
D
Scientific method
Question 5 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 6
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
Introduce the feeding slowly.
C
Assist the patient in fowler’s position.
D
Instill 60ml of water into the NGT after feeding.
Question 6 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 7
The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
A
Wait for the patient to return to bed and just leave the medication at the bedside.
B
After few minutes, return to that patient’s room and do not leave until the patient takes the medication.
C
Instruct the patient to take the medication and leave it at the bedside.
D
Leave the medication at the bedside and leave the room.
Question 7 Explanation:
This is to verify or to make sure that the medication was taken by the patient as directed.
Question 8
During the planning phase of the nursing process, which of the following is the outcome?
A
Nursing diagnosis
B
Nursing notes
C
Nursing care plan
D
Nursing history
Question 8 Explanation:
The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.
Question 9
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
Pulse rate greater than 100 beats per minute
B
Frequent bowel sounds
C
Respiratory rate greater than 20 breaths per minute
D
Blood pressure of 140/90
Question 9 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 10
Which expected outcome is correctly written?
A
“The patient will feel less nauseated in 24 hours.”
B
“The patient will have enough sleep.”
C
“The patient will identify all the high-salt food from a prepared list by discharge.”
D
“The patient will eat the right amount of food daily.”
Question 10 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 11
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 serum sodium levels
B
Low blood pressure
C
Warm, dry skin
D
Decreased urine output
Question 11 Explanation:
Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.
Question 12
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
Incorporation of both nursing and medical diagnoses in patient care
C
Making of individualized patient care
D
Development of a standardized NCP.
Question 12 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 13
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
Stop the infusion
C
Place a clod towel on the site
D
Call the attending physician
Question 13 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 14
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
Superstitious belief
B
Cultural belief
C
Health belief
D
Personal belief
Question 14 Explanation:
Health belief of an individual influences his/her preventive health behavior.
Question 15
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
Patient’s family came for a visit this morning.
C
That the patient verbalized, “My headache is gone.”
D
That the patient’s barium enema performed 3 days ago was negative
Question 15 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 16
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
36.3 degrees C
C
38.01 degrees C
D
40.03 degrees C
Question 16 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 17
Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?
A
“The patient will save urine for inspection by the nurse.
B
“The patient will take anti-diarrheal medication.”
C
“The patient will experience decreased frequency of bowel elimination.”
D
“The patient will give a stool specimen for laboratory examinations.”
Question 17 Explanation:
The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.
The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
Question 19
Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?
A
Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.
B
Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
C
Risk of injury related to autoimmune dysfunction
D
Anxiety related to impending surgery, as evidenced by insomnia.
Question 19 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 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?
A
Clear breath sounds
B
Oriented to date, time and place
C
Capillary refill greater than 3 seconds and buccal cyanosis
D
Hemoglobin of 13 g/dl
Question 20 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 21
Formulating a nursing diagnosis is a joint function of:
A
Patient and relatives
B
Doctor and family
C
Nurse and doctor
D
Nurse and patient
Question 21 Explanation:
Although diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.
Question 22
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
Caregiver
C
Patient advocate
D
Manager
Question 22 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 23
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
A
Use sterile gloves when obtaining urine.
B
Open the drainage bag and pour out the urine.
C
Disconnect the catheter from the tubing and get urine.
D
Aspirate urine from the tubing port using a sterile syringe.
Question 23 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 24
The theorist who believes that adaptation and manipulation of stressors are related to foster change is:
A
Imogene King
B
Sister Callista Roy
C
Virginia Henderson
D
Dorothea Orem
Question 24 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 25
Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting?
A
She signs her charting as follow: J.R
B
She writes in the chart using a no. 2 pencil.
C
She noted: appetite is good this afternoon.
D
She signs on the medication sheet after administering the medication.
Question 25 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.
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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
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
Pulse rate greater than 100 beats per minute
B
Blood pressure of 140/90
C
Respiratory rate greater than 20 breaths per minute
D
Frequent bowel sounds
Question 1 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 2
What is an example of a subjective data?
A
Heart rate of 68 beats per minute
B
Yellowish sputum
C
Client verbalized, “I feel pain when urinating.”
D
Noisy breathing
Question 2 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 3
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 3 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 4
During the planning phase of the nursing process, which of the following is the outcome?
A
Nursing care plan
B
Nursing diagnosis
C
Nursing history
D
Nursing notes
Question 4 Explanation:
The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.
Question 5
Which of the following is the most important purpose of planning care with this patient?
A
Development of a standardized NCP.
B
Making of individualized patient care
C
Incorporation of both nursing and medical diagnoses in patient care
D
Expansion of the current taxonomy of nursing diagnosis
Question 5 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 6
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 save urine for inspection by the nurse.
D
“The patient will experience decreased frequency of bowel elimination.”
Question 6 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 7
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
A
Open the drainage bag and pour out the urine.
B
Disconnect the catheter from the tubing and get urine.
C
Aspirate urine from the tubing port using a sterile syringe.
D
Use sterile gloves when obtaining urine.
Question 7 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 8
The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature?
A
40.03 degrees C
B
37.95 degrees C
C
36.3 degrees C
D
38.01 degrees C
Question 8 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 9
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 9 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 10
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
Wheezes
D
Rhonchi
Question 10 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 11
Which of the following is inappropriate nursing action when administering NGT feeding?
A
Instill 60ml of water into the NGT after feeding.
B
Assist the patient in fowler’s position.
C
Introduce the feeding slowly.
D
Place the feeding 20 inches above the pint if insertion of NGT.
Question 11 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.
The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
Question 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:
A
Cultural belief
B
Personal belief
C
Health belief
D
Superstitious belief
Question 13 Explanation:
Health belief of an individual influences his/her preventive health behavior.
Question 14
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 14 Explanation:
This is to verify or to make sure that the medication was taken by the patient as directed.
Question 15
What is the disadvantage of computerized documentation of the nursing process?
A
Accuracy
B
Concern for privacy
C
Rapid communication
D
Legibility
Question 15 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 16
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
Hemoglobin of 13 g/dl
B
Clear breath sounds
C
Capillary refill greater than 3 seconds and buccal cyanosis
D
Oriented to date, time and place
Question 16 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 17
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
Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.
C
Risk of injury related to autoimmune dysfunction
D
Anxiety related to impending surgery, as evidenced by insomnia.
Question 17 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 18
Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?
A
Trial and error
B
Routine
C
Intuition
D
Scientific method
Question 18 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 19
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
Call the attending physician
B
Slow that infusion to 20 ml/hr
C
Place a clod towel on the site
D
Stop the infusion
Question 19 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 20
The theorist who believes that adaptation and manipulation of stressors are related to foster change is:
A
Virginia Henderson
B
Imogene King
C
Sister Callista Roy
D
Dorothea Orem
Question 20 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 21
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 serum sodium levels
B
Warm, dry skin
C
Low blood pressure
D
Decreased urine output
Question 21 Explanation:
Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.
Question 22
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
Caregiver
B
Manager
C
Educator
D
Patient advocate
Question 22 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 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
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 24 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 25
Formulating a nursing diagnosis is a joint function of:
A
Doctor and family
B
Nurse and doctor
C
Nurse and patient
D
Patient and relatives
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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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