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