NAME ______________________ DATE _________ SCORE ______

INSTRUCTION: Select the best answer for each of the following questions. Read the questions well. NO ERASURES.

1. A nurse is formulating a plan of care for a client receiving enteral feedings. Which nursing diagnosis is of highest priority for this client?

a. altered nutrition, less than body requirements b. high risk for aspiration

c. high risk for fluid volume deficitd. diarrhea

Answer: BRationale: Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Options 1 and 4 may be appropriate nursing diagnoses but are not of highest priority. Option 3 is not likely to occur in this client. (Source: Mary Ann Hogan, Prentice Hall REVIEWS AND RATIONALES p204)

2. A nurse recognizes that which of the following interventions is unlikely to facilitate effective communication between a dying client and his or her family?

a. The nurse encourages the client and family to identify and discuss the feelings openlyb. The nurse makes decisions for the client and family to relieve them of unnecessary demandsc. The nurse assists the client and family in carrying out spiritually meaningful practicesd. The nurse maintains a calm attitude and one of acceptance when the family or client expresses angerAnswer: BRationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option A describes encouraging discussion of feelings and is likely to enhance communications. Option C is also an effective intervention, because spiritual practices give meaning to life and have an impact on how people react to crisis. Option D is also an effective technique, as the client and family need to know that someone will be there who is supportive and nonjudgmental. Option B describes the nurse removing autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which can further impair communication. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1041)

3. A client brought to the emergency department is dead on arrival (DOA). A family member of the client tells the physician that the client had a terminal cancer. The emergency department physician examines the client and asks a nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which of the following responses to the family is most appropriate?

a. “it is required by federal law. Why don’t we talk about it, and why don’t you tell me why you don’t want the autopsy done?

b. “the decision is made by the medical examiner.”

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c. “I will contact the medical examiner regarding your request.”d. “An autopsy is mandatory for any client who is DOA.”Answer: CRationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1044)

4. A nurse is developing a postoperative plan of care for a 40-year male Filipino client scheduled for an appendectomy. The nurse most appropriately includes in the plan of care to:a. inform the client that he will need to ask for pain medication when

neededb. offer pain medication when nonverbal signs of discomfort are identifiedc. offer pain medication on a regular basis as prescribedd. allow the client to maintain control and request pain medication on his

ownAnswer: CRationale: Filipinos view pain as part of living an honorable life. The client may appear stoic and be tolerant of a high degree of pain. Health care providers need to offer, and in fact encourage pain relief interventions for the Filipino client who does not complain of pain despite physiological indicators. Option c is the most appropriate intervention to include in the plan of care. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1140)

5. A nurse has developed a plan of care for a client who is in traction and documents a nursing diagnosis of Self-Care Deficit. The nurse evaluates the plan of care and determines that which of the following observations indicates a successful outcome?

a. the client allows the nurse to complete the care on a daily basisb. the client allows the family to assist in the care c. the client refuses cared. the client assists in self-care as much as possible,

Answer: DRationale: A successful outcome for the nursing diagnosis of Self-Care-Deficit is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the clients condition. The nurse would determine that the outcome is unsuccessful if the client refused care or allows others to do the care. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 39)

6. A registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a registered nurse and two nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the nursing assistants?

a. A client who requires a 24-hour urine collectionb. An elderly client requiring assistance with a bed bath and frequent

ambulationc. A client on a mechanical ventilator who requires frequent assessment and

suctioning

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d. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

Answer: BRationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine and frequent ambulation can most appropriately be provided by the nursing assistant considering the clients identified in each of the options. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the registered nurse. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 476, 477)

7. Nursing has been focused on health and caring. Traditionally, nursing was concerned with:

a. attending to the poorb. keeping people healthy and wellc. caring for the sick and the infirmedd. working with the “dregs” of society

Answer: C Rationale: In the past, the traditional nursing role was one of humanistic caring or both men and women comforted and cared for the sick and those unable to care for themselves; was nurturing, comforting and supporting. Nurses are mentioned occasionally in the Old Testament as women who provided care for the infants and children, for the sick and dying. (source: FNP by Kozier, 5th ed., p. 4)A – anyone who was sick is being provided with care whether poor or richB – is the concern in modern timesD – is unrelated

8. Nursing has evolved from a subservient role to one that is:a. people-oriented c. coordinate roleb. handmaid of doctor d. self-regulatory

Answer: DRationale: Means that modern nurse can act independently without being subjected to another person’s will /want. The nurse is constantly assuming responsibilities in patient care and are fulfilling expanded nursing roles, for example, those of the nurse generalist, the nurse clinician and advanced nurse practioner. (Source: FNP by Kozier, 5th ed., p. 21)A- unrelated to the question but nowadays nursing is people –orientedB- is a traditional role of nurse; formerly the nurse was the sole prerogative of

the physician C- in the past and in the present the nurse needs to coordinate with other

health care team members

9. The nurse’s understanding of human needs is essential to effective nursing care. Which statement about Maslow’s need theory is true?

a. risk factors are safety needsb. unmet needs cause illness c. priorities on human do not varyd. self-actualization is achieved on retirement

Answer: DRationale: On retirement self-actualized person is realistic, sees life clearly, and is objective about his or her observation.A – risk factor can cause a disease

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B – needs may be deferred and will not cause immediate illnessD – priorities may be altered and vary among humans(Source: FNP by Udan, yr 2001, p. 17)

10. A priority safety need in health is:a. sense of belonging c. environmental hygiene b. social acceptance d.. a gunless society

Answer: CEnvironmental hygiene should be analyzed to determine health hazard in en vironment. People’s need for safety is lifelong. The environment contains many hazards, both seen and unseen. The society with a gun which bay kill people is an obvious hazard. Microorganisms and radiation are unseen hazards. A primary concern of nurse is awareness of what constitute a safe environment for a particular person and how this environment can be achieved. (Source: FNP by Kozier, 5th ed., p. 705)A – is not susceptible/prone to accidentsC & D are the same and have nothing to do with safety needs

11. The health-illness continuum concept views health as:

a. a spectrum that ranges from extreme state of ill health to peak wellnessb. continuous adjustment to the changes of the external ad internal body

environmentc. health-illness curve is subjected to biorhythmic influencesd. hierarchy of human needs based upon satisfying the needs of the lowest end

of the continuum first Answer: A

One way to measure a person’s level of wellness is the use of the health-illness continuum, according to this model, health is constantly changing state, with high level wellness and death being the opposite ends of a graduated scale. or continuum. Travis described health-illness continuum. (Source: FNP by Taylor, 3rd ed, p. 54)B – pertains to Adaptation theory in which there is adjustment of living matter to other living things and to environmental conditions. Adaptation is a dynamic or continuously changing process that effects change and involves interaction and response. Human adaptation occurs on 3 levels – the internal (self), the social (others/external) and the physical (biochemical reactions) (Source: FNP by Taylor, 3rded, p. 67)D –refers to Maslow’s hierarchy of needs. Maslow’s hieararchy of needs is an interdisciplinary theory that is useful for designing priorities of care. The hierarchy of human needs arranges the basic needs in five levels of priority. The most basic or first level includes physiologic needs, such as air, water and food. The second level includes safe and security needs, which involves physical and psychological security. The 3rd level contains love and belonging needs, including friendships and sexual love. The 4th level encompasses esteem and self-esteem, which involve self-confidence, usefulness, achievement and self-worth. The final level is the need for self-actualization, the state of fully achieving potential and having the ability to solve problems and cope realistically with life’s situations.The hierarchy of needs is a useful way for nurses to plan individualized care for a client. One need may take priority over another (such as restoration of an adequate airway before the nurse educates the client in adjusting to an emotional conflict. The nurse uses priorities to organize nursing diagnosis, develop goals, and expected outcomes and select nursing intervention (Source: FNP by Taylor 3rd ed, p. 92)

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12. Leavell and Clark model of health is also known as the:a. Eudemonistic modelb. Adaptation modelc. Health-illness Continuum modeld. Ecologic model Answer: DEcologic model avers that there are three interactive factors that affect health and illness. The 3 factors are as follows: (1) agent-any factor or stressor that can effect illness or disease; (2) host- persons who may or may not be affected by disease; (3) environment – any factor external to the host that may or may not predispose the person to a certain disease. (source: FNP by Udan,yr. 2001, p. 25)A. – is one of the models described by SmithB – Adaptation model was presented by Sister Callista Roy in which she viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. She believed that adaptive human behavior is directed toward an attempt to maintain homeostasis or integrity of the individual by conserving energy and promoting the survival, growth, reproduction and mastery of the human system (source: FNP by Udan,yr. 2001, p. 5)C – Travis described health-illness continuum. One way to measure a person’s level of wellness is the use of the health-illness continuum, according to this model, health is constantly changing state, with high level wellness and death being the opposite ends of a graduated scale, or continuum (Source: FNP by Taylor, 3rd ed, p. 54)

13. Health promotions should assume a major focus of nursing care for all types of patients in all setting because:

a. health promotion behaviors are the essential components of health restoration and rehabilitation

b. health promotion behaviors help persons maintain or achieve a high level of functioning

c. the effect of demographic variables on health promoting behaviors is clearly established

d. health promotion behaviors will decrease occupational health risksAnswer: BHealth promotion is any activity undertaken for the purpose of achieving a higher level of health and well-being. It is directed toward improving well-being and actualizing the health potential of individuals, families, groups, and communities. Health promotion is more than the avoidance or prevention of disease. (source: FNP by Kozier, 5th ed., p. 259)A, C, D are under letter BA – the tertiary prevention is included is a health promotion to restore the optimum level of functioning within the constraints of the disability. And also to prevent further disability

14. Prescribed the development of faith:A. Kolherg C. PetersB. Westerhoff D. Fowler Answer: DFowler described the development of faith. He believed that faith, or the spiritual

dimension is a force that gives meaning to a person’s lifeA- Kohlberg suggested three levels of moral development that encompasses 6 stages B- Westerhoff proposed that faith is a way of behavingC – Peters proposed a concept of rational morality based on principles

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(Source: FNP by Udan,yr. 2001, p. 8-9)

15. Aside from body temperature, the PR and RR will be likewise taken. Which of the ff. instances can the nurse take Sonny’s RR?A. while taking the pulse C. while taking the temperature

B. while conversing with the client D. while moving the patientAnswer: CPR and RR can be taken while taking client’s temperature, you can’t take PR and RR while conversing with or moving the client because the result could be altered. Moving the client could increase both his RR and PR.

16. Inspection of the respiratory system does not include assessment of:A. rhythm C. retractionB. anteroposterior diameter D. fremitus

Answer: DFremitus is a palpable vibration transmitted through the bronchopulmonary system on speaking you can elicit this by touching areas of the lungs. Anteroposterior diameter, retraction and rhythm can be all examined through inspection with the use of both eyes of the examiner. (Source: Lippincott Manual of Nursing Practice, 7th ed., p.65)

17. A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops four times a day (QID). The nurse should administer the medication by gently dropping the medication onto which of the following areas? a. Sclera by the inner canthus.b. Center of the cornea.c. Lower conjunctival sacd. Sclera by the outer canthusAnswer: C Eye drops are placed in the lower conjunctival sac to prevent damage to the cornea and to facilitate coating the eye with the medication. The other options are incorrect. (Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p337)

18. Mr. Stevens, 77 years old, need to complete a 24 hour urine specimen. In planning his care, which of the following measures is most important?a. Place a sign stating “Save all urine” in the bathroom.b. Keep the urine specimen in the refrigerator.c. At the beginning of the test, instructing him to empty his bladder and save this voiding to start the collection.d. Use a sterile receptacle to collect the urine.Answer: B Timed specimens generally either are refrigerated or contain a preservative to prevent bacterial growth or decomposition of urine components.(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p. 769)

19. When assisting with a bone marrow biopsy, the nurse should take which of the following actions?a. Stand in front of the client and support the back of the neck and knees.b. Assist the client to a right side lying position after the procedure.c. Observe for signs of dyspnea, pallor and coughing.d. Assess for bleeding and hematoma formation for several days after the procedure.Answer: C The client may experience pain when the marrow is aspirated. Monitor and support the client by explaining the procedure. Help the client assume a supine position (with one

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pillow if desired) for a biopsy of the sternum or a prone position for a biopsy of either iliac crests. Observe the client for pallor, diaphoresis, and faintness due to bleeding or pain. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 780)

20. Pain in the elderly requires careful assessment because older people have which of the following characteristics?a. Are likely to experience chronic painb. Increased pain tolerancec Experience reduced sensory perceptiond. Increased pain toleranceAnswer: C Elderly clients may have decreased perception of sensory stimuli and a higher pain threshold. Chronic disease processes such as diabetes or peripheral vascular disease may interfere with normal nerve impulses transmission. Sensory perception defects such as impaired affect pain perception by the Central Nervous System. (Source: Hogan REVIEWS AND RATIONALES p235)

21. A client is hospitalized for the first time. Which of the following actions ensures the safety of the client?a. Keep lights on all the time.b. Keep side rails up at all times.c. Keep all equipment out of view.d. Keep unnecessary furniture out of the way.Answer: D Rationale: The environment has to be clutter free. Therefore, unnecessary pieces of equipment or furniture have to be out of the way. Lights on and side rails up are not mandatory at all times. It is unnecessary to keep equipment out of view.(Source: Hogan REVIEWS AND RATIONALES p204)

22. Which is a typical gender role behavior in the United States?a. Men are expected to be nurturing as well as assertive.b. Men are given permission to wear a wide variety of clothing.c. Women are most responsible for child rearing activities.d. Women should express their feelings in a controlled manner.Answer: ARationale: In North America, expected adult male roles include breadwinner, heterosexual lover, father and athlete. Expected male behaviors include wearing trousers, demonstrating physical strength and expressing feelings in a controlled fashion. Women are expected to express emotion more freely. (Option D) and to be gentler in their physical responses; they also have a broader choice of clothing than men do. (option B). Men make loving sensitive single fathers. Women are capably functioning as competitive and assertive executives and world leaders. (Option C) (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 974)

23. There was a large disaster in the community. Many family homes were destroyed and many individuals were injured. The community health nurse and home health nurse assume their roles. What is the responsibility of a home health nurse?a. assessing and treating individuals injuredb. providing a safe water supplyc. establishing communication and support systemd. monitoring for communicable diseasesAnswer: C

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Nurses committed to family centered care involve both the ailing individual and the family in the nursing process. Through this interaction with families nurse can give support and information. Nurses make sure that not only the individual but also each family member understands the disease, its management and the effect of these factors on family functioning. The nurses also help families cope with the realities of the illness and changes it may have brought about. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 196)

24. Sweating maximizes heat loss through:a. radiation c. convectionb. conduction d. evaporation

Answer: DRationale: Evaporation is the loss of heat when water or sweat on the person’s skin converted to a vapor.A- Radiation is the transfer of heat from the person to cooler surfaces and objects not in direct contact with the person. Environmental factors: Cold outside building walls and windows.B- Conduction is the transfer of heat when the person comes in direct contact with cooler surface or objects. Environmental factors: cold stethoscope, cold hands of caregiverC- Convection is the transfer of heat when a flow of cold air passed over the person’s skin. Environmental factors: drafts air-conditioning duct(source: pathophysiology – Bullock, p.120)

25. In noting the Ronald’s pulse, the nurse should that the pulse is most perceptible at a site where:a. venous valves rhythmically reflect pulsationb. peripheral resistance is highestc. the blood vessel is most easily distensible by the pressure of blood flowdd. an artery passes over a bony prominence Answer: DRationale: The pulse is a wave of blood created by contraction of the left ventricle wherein blood enters the arteries with each heart beat. It can be taken over the bony prominences. Ex: in the temporal where the temporal artery passes over the temporal bone of the headA, B, C will give an incorrect readings(source: FNP by Udan,yr. 2001, p. 81)

26. All but one causes tachycardia: a. fasting c. cigarette smoking b. severe pain d. anxietyAnswer: CRationale: Cigarette smoking causes vasoconstriction but not necessarily causing tachycardia.A-If there’s prolonged fasting it could result to hypoglycemia, signs of hypoglycemia are: sweating, tremor, nervousness, TACHYCARDIA, lightheadedness and confusion. (Source: Lippincott Manual of Nursing Practice, 7th ed., p. 849 – 853) B- severe pain is a reaction to a stimulus that produces a generalized response. Sympathetic reaction increases the energy necessary to mobilize an emergency response. Tachycardia is one of the characteristic responses to pain (source: pathophysiology – Bullock) D- an individual who has anxiety experiences physiologic manifestation related to the “fight-flight” response and could result in cardiovascular stimulation thereby causing tachycardia ( source: Lippincott Manual of Nursing Practice 7th ed., p. 1626)

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27. The BP of your patient Paula, 42, a known hypertensive is 130/80 mmHg on admission. Will you give a standing order of Plendil 2.5mg OD?a. yes, because her anxiety make her BP riseb. yes, because she may want to take it since her BVP is variablec. no, because fasting may be required laterd. no, because her BP is borderlineAnswer: ARationale: The decision should be made by the nurse in giving the meds not by the client. Since she is known hypertensive, the nurse should give the meds to control her BP even though her BP is within normal range.

28. Before taking the patient’s BP, which of the ff. must the nurse do?a. cleanse the patient’s antecubutal fossa with an alcohol spongeb. note the patient’s physique and agec. wipe the cuff and the valve with dry clothd. palpate the brachial pulseAnswer: BRationale: BP increases with age or older people have higher BP due to decreased elasticity of blood vessels. You have to note first the client’s age to determine on what normal range of BP the client will fall into. Noting the client’s physique would be a factor that could affect BP. BP generally is elevated among overweight and obese people.A- it is not necessary to do this unless the antecubital fossa is dirty C- It’s not necessary to do this D – palpatation of brachial pulse is done during deflation of the BP, which is commonly used technique to obtain BP measurement often when a client is in shock. Wherein it’s difficult to hear BP with a standard stethoscope (source: MS nursing 6th ed, J. Black, p. 2252)

29. A client is refusing to take her daily antihypertensive medication. The nurse has explained to the client why the medication is important and the client verbalizes understanding but doesn’t want to take the medication. Which is the best nursing action?a. Inform the client that the medication needs to be taken until the nurse gets an order to discontinue it.b. Administer the medication because it is important for the client.c. Withhold the medication and report it to the physician.d. Withhold the medication and complete an incident report.Answer: CRationale: A client has the right to refuse a medication regardless how important it may be to his or her health. Withholding the medication because of client refusal is not an incident and does not require an incident report, but it should be documented and reported to the physician. The other options are incorrect. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p338

30. The nurse evaluates the results of laboratory tests completed on a client. Which of the following values indicate an abnormality related to nutritional status?a. Albumin 5 g/dlb. Serum potassium 2.0 mEq/lc. Blood urea nitrogen (BUN) 15 mg/dld. Urinary creatinine 800 mg/24 h in an adult femaleAnswer: B

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Rationale: This is an indicative of potassium depletion that occurs in severe cases of malnutrition. The other options are of normal values.(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p204)

31. An adult who has failed to satisfactorily resolve the developmental task of adolescence which is identity versus confusion may show which behavior?a. goes along with the crowd in all activitiesb. asserts independencec. has difficulty working as a member of a teamd. is unable to express personal desiresAnswer: C Rationale: Some behaviors indicating negative resolution to the developmental task – identity versus confusion are failing to assume responsibility for directing one’s own behavior, accepting the values of others without question and failing to set goals in life.Options a and b are behaviors indicating positive resolution to the developmental task –identity vs. confusion. Option d is a negative behavior if autonomy among toddlers has not been met.(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 958)

32. A client received a severe burn in a house fire. On the second day of hospitalization, the physician orders the client to receive albumin. The nurse explains to the client that which of the following is the rationale for albumin administration?a. Improve the level of clotting factors and prevent bleeding.b. Replace the lost red blood cells and reduce the anemia.c. Provide proteins to increase the osmotic pressure in the blood.d. Provide fluid resuscitation to prevent dehydration.Answer: CRationale: Protein is responsible for a significant portion of the osmotic pressure found in the blood vessels and maintains fluid within the vessels. In burn injuries, protein is lost allowing fluid to escape into the tissues. Albumin is used to replace the lost proteins and pull fluids from the interstitial space back into the vascular system. It does not contain clotting factors, red blood cells, nor is there enough fluid volume to consider it as part of primary fluid resuscitation. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p337

33. The nurse is taking a nursing history on an adolescent client. The nurse can best facilitate communication with adolescent client by making which of the following statements?a. We can talk about this with your mother.”b. “Our teenage girls also feel depressed.”c. “If you read the pamphlet, you’ll know all you need to know.”d. “Tell me about the last time you had sexual intercourse.”Answer: B Rationale: Option B indicates that the client is not alone, which can enhance communication by affirming the clients’ feelings. Adolescents will feel more willing to discuss private issues if parents are not present and if they understand that their concerns are common with other teens. Questions should be sensitively worded rather than intrusive. Written instructions should supplement teaching rather than being the primary vehicle for teaching. (Source:Hogan REVIEWS AND RATIONALES p132

34. Providing health care involves the utilization of the nursing process. The nursing process is:a. a method for processing the care of many patients

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b. a method for diagnosing and treating human responses to actual or potential health problemsc. a method for diagnosing health problems/diseasesd. a logical systematic problem-solving method for providing nursing careAnswer: DA- is more on implementationB- pertains to nursing dx and implementationC- pertains to nsg dxA, B, C are all components of nursing process that must be all present done in a systematic way(source: FNP by Udan, yr 2001, p. 65-70)

35. Which statement best describes the purpose of nursing diagnosis?a. identification of problems areasb. specification of patient’s health care needsc. organization of the assessment data gathered dd. preparation of the clinical abstractAnswer: BRationale: The purpose of nursing diagnosis is to identify the client’s health care needs and to prepare dx statementsA- pertains to medical diagnosisC and D refer to assessment

36. Nursing diagnosis is the result of:a. review of data base recordedb. observation, interview and PEc. analysis of health data collectedd. information collected on the patient’s conditionAnswer: CA, B and D all pertains to assessment

37. Which of the ff statement is not true of the nursing diagnosis?a. it states etiology of the problemb. it is disease orientedc. it is guided by independent nursing actiond. it is complementary to medical diagnosisAnswer: BThis refers to medical dx. A medical dx is made by a physician and refers to a condition that only a physician can treat. Medical dx refer to disease processes – specific pathophysiologic responses that fairly uniform from one client to another.All other options are true of nsg dxNursing dx has 3 components: (1) the problem statement or the diagnostic label – describes the client’s health problem or response for which the nursing therapy is given; (2) the etiology – identifies the probable causes of the health problem, and (3) defining the characteristics which are the signs and symptoms that indicate the presence of particular diagnostic label.C- registered nurses are responsible for making nursing dx and (D) it is complementary to medical diagnosis. Nursing dx relate to the nurse’s independent functions, that is, the areas of health care that are unique to nursing and separate and distinct form medical management. With regard to medical dx nurses are obligated to carry out physician-prescribed therapies and treatments, that is, dependent functions.(source: FNP by Kozier, 5th ed., pp. 107-111)

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38. Betina, a dyspneic ask the nurse if she can be bathe sitting on a chair. The nurse response should be:a. ”I’m sorry, I’m only allowed to bathe you in bed”b. “Since you are more comfortable on the chair, I will be happy to assist you there”c. “My supervisor would be upset if she sees me bathing you on the chair”d. “This is against hospital policy and how I have been taught.”Answer: BClient may be bathed in different positions whether on the bed or in the chair as long as the client is comfortable. Since the client is dyspneic, she is more comfortable in a sitting position and it’s not contraindicated to bathe her in the position.A, C & D are nontherapeutic approach which will make the client irritated that could increase her dyspnea further.

39. Patrick, 20 is diagnosed to have epilepsy. The nurse noticed that he is wearing a rosary bead around his neck. The nurse should:a. remove the rosary beads and give this to the family m ember for safekeepingb. respect the patient’s right to wear the beadsc. place the beads in an envelope and store them in the agency’s safed. place the beads on the bedAnswer: BWearing beads is not contraindicated in this client. The nurse should respect the client’s belief and right of wearing a rosary bead around his neck. Wearing beads will not precipitate or predispose the client to having an epileptic episode.A, C, D are not necessary

SITUATION: Mrs. Dela Pena, your adult patient is unable to sleep on her first night of hospitalization. She appears restless and anxious.

40. A client with cervical traction has been on bed rest for two weeks. The traction is discontinued and the client needs to ambulate. Prior to getting the client out of bed, what is the initial action by the nurse?a. Assess lower leg muscle strengthb. Raise the head of the bed slowlyc. Provide the client with a caned. Get a neck brace for the clientAnswer: B Rationale: Orthostatic hypotension is a blood pressure that falls when the client sits or stands.It may occur if the client has been on bed rest. It is the result of the peripheral vasodilatation in which blood leaves the central organs, especially the brain, and moves to the periphery, often causing the person to faint. To decrease the problem, gradually elevate the head of the bed to assist the client to asitting position .Kozier FUNDAMENTALS OF NURSING 7th Ed p 511 ( Source: Hogan NURSING FUNDAMENTALS p291)The nurse should also assess the strength of the leg muscles but this is not the priority. A neck brace may not be ordered.

41. Although clients may exhibit calm behavior, physical evidence of stress may still be manifested bya. decreased heart rateb. hyperventilationc. dilated peripheral blood vesselsd. constricted pupilsAnswer: B

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Rationale: The rate and depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation. The other physiologic indicators of stress are pupils dilate to increase visual perception when serious threats to the body arise, the heart rate and cardiac output increase to transport nutrients and by products of metabolism efficiently, skin is pallid because of constriction of peripheral blood vessels, an effect of norepinephrine., urinary output decreased (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1016)

42. All of the following may be considered normal or “healthy” types of grief EXCEPTa. dysfunctional griefb. abbreviated griefc. disenfranchised griefd. anticipatory griefAnswer: ARationale: Normal grief reaction may be abbreviated or anticipatory. Abbreviated grief is brief but genuinely felt. Anticipatory grief is experienced in advance of the event. Disenfranchised grief occurs when a person is unable to acknowledge the loss to other persons. Unhealthy grief – that is pathologic, or dysfunctional grief may be unresolved or inhibited. Kozier FUNDAMENTALS OF NURSING 7th Ed p 1034

43. A postoperative client has to be assisted by the nurse for coughing and breathing exercises to prevent postoperative complications. This is best accomplished by planninga. huff coughing every two hours and as needed.b. coughing exercises 1 hour before meals and deep breathing 1 hour after meals.c. diaphragmatic and pursed-lip breathing 5 – 10 times four times a day.d. forceful coughing as many times as tolerated.Answer: CRationale: A commonly employed breathing exercise is abdominal (diaphragmatic) and pursed – lip breathing. Abdominal breathing permits deep full breaths with little effort. Pursed-lip breathing helps the client develop control over breathing. The pursed lips create a resistance to the air flowing out of the lungs, thereby prolonging exhalation and preventing airway collapse by maintaining positive airway pressure. The client purse the lip as if about to whistle and breaths out slowly and gently, tightening the abdominal muscles to exhale more effectively. The client usually inhales to a count of 3 and exhales to a count of 7. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1302)Forceful coughing often is less effective than using controlled or huff coughing techniques.

44. A nurse is performing oropharyngeal suctioning on an unconscious client. Which of the following actions is safe?a. Gently rotate the catheter while applying suction.b. Apply suction for 5 seconds while inserting the catheter and continue for another 5 seconds before withdrawing.c. Insert the catheter approximately 20 cm while applying suction.d. Allow 20 – 30 seconds intervals between each suction, and limit suctioning to a total of 15 minutes.Answer: ARationale: Gentle rotation ensures that all surfaces are reached and prevents trauma to any one area caused by prolonged suctioning. In oropharyngeal suctioning, the catheter should be advanced 10 to 15 cm; 20 cm is the distance for tracheal suctioning. 15 minutes of suctioning and applying suction while inserting the catheter can cause trauma to the mucous membranes.(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p204)

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45. The nurse demonstrates proper technique of performing back massage whena. Using firm, continuous pressureb. Pouring the lotion directly onto the client’s skinc. Continuing the massage for at least 15 minutesd. Using the fingertips to perform the stroking motionAnswer: ARationale: Back massage relieves muscle tension, promotes physical and mental relaxation, and relieves insomnia. It is applied in a firm, continuous pressure without breaking contact with the client’s skin. Pour a small amount of lotion onto the palms of your hands and hold it for a minute or the lotion bottle can be placed in a bath basin filled with warm water because back rub preparations tend to feel uncomfortably cold to people. Warming the solution facilitates client’s comfort. Using your palm and not the fingertips, begin in the sacral area using smooth, circular strokes; move your hands up the center of the back and over both scapulae. Massage in a circular motion over the scapulae. Move your hands down to the sides then to the areas over the right and left iliac crests. Repeat above for 3-5 minutes obtaining more lotion as necessary. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1125 – 1126)

46. Which statement indicates a need for further teaching of the home care client with a long term indwelling catheter?a. “Intake of cranberry juice may help decrease the chances of developing infection.”b. “I will keep the collecting bag below the level of the bladder at all times.”c. “I should use clean technique when emptying the collecting bag.”d. “Soaking in warm tub bath may ease the irritating feeling from having a catheter.”Answer: DRationale: Sitting in a tub allows bacteria easier access into the urinary tract. Take a shower rather than a bath tub. Acidifying the urine of clients with retention catheter may reduce the risk of urinary tract infection and calculus formation. Foods such as eggs, cheese, meat poultry, whole grains, cranberries, plums and prunes and tomatoes tend to increase the acidity of the urine.Keep the urine drainage bag below the level of the bladder.Follow instruction for clean technique. Wash hands well with soap and warm water prior to handling or performing catheterization.(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1278)

47. A client who is unconscious needs frequent mouth care. In what position should a client be placed when providing mouth care?a. Trendelenburg positionb. Fowler’s positionc. Supine positiond. Side-lying positionAnswer: DRationale: In the side lying position, fluid is more likely to flow readily out of the mouth or pool in the side of the mouth where it can easily be suctioned. Fowler’s position and Trendelenburg positions are not appropriate since the unconscious client does not have the control to stay up in those positions. The supine position is not safe as the client may aspirate the fluids. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p204

48. The structure of the nervous system that controls sleep is the:a. hypothalamus c. medulla oblangatab. reticular formation d. cerebral cortex

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Answer: BRationale: (Reticular formation assist in regulation of skeletal motor movement and spinal reflexes) one of the components of reticular formation is the reticular activating system (RAS), which controls the sleep wake cycle and consciousness.A – hypothalamus regulates stress response, sleep, appetite, body temperature, fluid balance and emotions (source: Saunders Comprehensive Review, p. 807, 2003)C – controls HR, respiration; primary respiratory center (Source: FNPby Udan yr 2001,p. 83)D – is responsible for the conscious activities of the cerebrum (source: Saunders Comprehensive Review, p. 807, 2003)

49. Which of the ff statements is true?a. regular bedtime promotes sleep c. sedatives reduces sleepless nightsb. ill persons sleep more than normal d. a high protein diet disturbs sleepAnswer: ARationale: Regular bedtime pattern will make the body get used to it, thereby promoting sleep at the scheduled timeB – during illness person has an interrupted sleep brought about by discomfort from illnessC- it’s not necessary to administer sedatives just to reduce sleepless nights. It should be use judiciouslyD- protein contains amino acid tryptophan which is a CNS depressant thus promotes sleep(source:FNP by Kozier, 5th ed., p. 956)

50. These are characteristics most patients associate with sleep and rest, except:a. feeling of acceptanceb. assured of response to call when neededc. free from discomfortd. bedtime medications received on timeAnswer: DRationale: Schedule meds on time especially diuretics to prevent interruption of sleepA- decrease stress on the psychological part of the clientC-creates a restful environment

51. Carol, a college student was brought by her mother in the ER because of fever and cough. Which of the ff actions would you do first on admission?A. orient the mother on hospital deposit policy C. take patient to her bedB. greet the patient and her mother D. take the patient’s VSAnswer: BRationale: Shows acceptance of both the client and mother, builds rapport and lessens anxietyA, C, D are not the priority at this time. They could easily be done after you had build trust/rapport with them (source: FNP by Udan yr 2001, p. 51)

52. Meperidine (Demerol) IM injection should be given to the patient. Prior to injecting the medication, the nurse aspirates and finds blood in the syringe . What is the appropriate nursing action by the nurse? a. Withdraw the needle, discard the medication, and begin again with the medication administration.b. Withdraw the needle, cleanse the needle and the new injection site with alcohol, and administer the medication.

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c. Continue to administer the medication because it is compatible with blood and would not present a harmful effect.d. Continue to administer the medication because the needle has hit a capillary and would not be an intravenous administration.Answer: A Rationale: f blood returns while aspirating during an IM injection, the nurse should discard and prepare a new injection. Blood indicates that the needle has entered a blood vessel, and medication injected directly into the bloodstream may be dangerous. Kozier FUNDAMENTALS OF NURSING 7th Ed p 831

53. A client has a previous blood pressure reading of 138/74 and pulse rate of 64 beats / minute. In order to obtain an accurate reading, how long should the nurse wait before she releases the blood pressure cuff?a. 30 – 45 secondsb. 1 – 1.5 minutesc. 10 – 20 secondsd. 3 – 3.5 minutesAnswer: BRationale: Release the pressure completely in the cuff, and wait 1 – 2 minutes before making further measurements. A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur. Kozier FUNDAMENTALS OF NURSIG 7th Ed p515

54. The nurse will remove the heating pad after a 30 minute application, when the client requests to leave it in place. The nurse will explain thata. It will be acceptable to leave the pad in place if the temperature is reduced to between 40.6 – 46 C ( 105 and 115 ).b. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed.c. heat application for longer than 30 minutes can actually cause the opposite effect ( constriction ) of the one desired ( dilation ).d. it will be acceptable to leave the pad in place as long a it is moist heat.Answer: CRationale: The rebound phenomenon occurs at the time the maximum therapeutic effect of the hot or cold application is achieved and the opposite effect begins. If the heat application is continued, the client is at risk for burns because the constricted blood vessels are unable to dissipate the heat adequately via the blood circulation.(Source:Kozier FUNDAMENTALS OF NURSING 7th Ed p 885)

55. The abdominal suture line of a post operative client for abdominal procedure has been assessed. Which characteristics would indicate a possible delay in wound healing?a. Sanguineous drainage in the wound collection device.b. Suture line clean and dryc. Incision healing by primary uniond. Purulent drainage on dressingAnswer: D Rationale: The temperature of the water in the bag are considered safe and provide the desired effect : normal adult and child over 2 years, 46 – 52C (115 – 125F), debilitated or unconscious adult, or child under 2 years, 40.5 – 46C ( 105 – 115F). The heat application should be removed after 30 minutes or in accordance with agency protocol. Purulent drainage is a sign of infection. The wound healing will be delayed if infection is present. Primary intention is a normal process of wound healing and a clean and dry suture line is normal. Sanguineous drainage indicates the drainage of blood that is in the

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tissues.(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p290)

56. Which of the following sounds would the nurse expect to find on auscultation of normal lung?a. hyperresonnance over the left lower lobeb. tympany over the right upper lobec. dullness above the left 10th intercostals spaced. resonance over the left upper lobeAnswer: DRationale: Resonance over the left upper lobe - Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach.Kozier p579

57. For accurate inspection of body parts during PE, the important principle to observe is:a. adequate exposure of all body surfaces c. positioningb. good lighting d. ensure detailed explanation of the procedureAnswer: CRationale: Correct positioning elicits correct result during PE. For example, if the client is being examined for chest and lungs, the client should be positioned sitting on a chair or bed to get accurate results or to allow full lung expansion and better visualization of upper body symmetry. (source: MS by Black, 6th ed., p. 181)A- only the part of the body needed to be examined should be exposed, drape the rest of the body appropriatelyB- PE is conducted in a quiet, well-lit room with consideration to client’s privacy and comfortD- provides simple, short and clear explanations of the procedures to the client to avoid anxiety and encourage cooperation(Source: Lippincott Manual of Nursing Practice, 7th ed., p.51)

58. In physical examination, less tender body areas are palpated first to:a. reduce patient’s apprehension c. properly positioned clientb. ensure patient’s cooperation d. obtain accurate findingsAnswer: DRationale: Less tender areas should always precede because heavy pressure on the fingertips can dull the sense of touch giving inaccurate results. The effective of palpation depends largely on the client’s relaxation. Nurses can assist a client to relax by (a) draping the client appropriately, (b) positioning comfortably (c) ensuring that their own hands are warm before beginning, and (d) commencing palpation with areas that are not painful. (source: FNP by Kozier, 5th ed., p. 469)

59. You are going to assess patient’s lung sounds. Which of the following techniques of PE will you use?a. percussion and auscultationb. inspection, palpation, percussion, auscultationc. inspection, auscultation, percussion, palpationd. auscultation, percussion, palpationAnswer: APercussion normally reveals resonance over symmetric areas of lung. Percussion sound may be altered by poor posture and/or presence of excessive tissues. On auscultation, breath sounds are noted with the use of stethoscope.

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You can’t assess lung sounds through palpation (touching) or inspecting (use of sense of sight) (source: Lippincott Manual of Nursing Practice, 7th ed., pp. 65-66)

60. Which of the ff describes an adventitious breath sounds?a. dull c. hollowb. crackles d. clearAnswer: BRationale: Adventitious breath sounds are abnormal sounds superimposed on normal breath sounds. It includes crackles, rhonchi, wheezes and pleural rubsA, C, D are all normal breath sounds that can be elicited through percussion and auscultation depending on what area of the lungs you will examine (Source: Lippincott Manual of Nursing Practice, 7th ed., p. 67)

61. Your client is for routine fecalysis. Which of the ff results would not be normal?a. odor – foul-smelling c. (+) dead bacteiab. amorphous phosphates (+) d. (+) mucusAnswer: DRationale: Presence of mucus in the stool from routine fecalysis may indicate infection such as chronic ulcerative colitis and shigellosisA, B, D are normal to be present in stool(Source: Lippincott Manual of Nursing Practice, 7th ed., p. 572)

62. Result of the lab test of the patient show his total serum Calcium is 4.0 mEq/L. the normal serum calcium in an adult is a. 4.5 – 5.5 mEq/L c. 1.5 – 2.5mEq/Lb. 3.5 – 4.5 mEq/L d. 9.5 – 10.5mEq/LAnswer: ARationale: C- is the normal lab value of MgB & D are distractors.(source: FNP by Udan, yr 2001, p.265)

63. The ff are clinical signs of hypernatremia, except:a. extreme thirst c. disorientationb. red, swollen tongue d. urine specific gr.= 1,25Answer: BS/sx of hypernatremia are dry, sticky mucous membrane, flush skin, oliguria or anuria, increase urine sp. gr., disorientation, thirst and rough and dry tongueRed swollen tongue indicates Vit. B12 deficiency(Source: Lippincott Manual of Nursing Practice, 7th ed., p. 711)

64. Richard has an oxygen therapy given via facemask. The primary effect of oxygen therapy is to:a. increase oxygen in the tissues and cellsb. increase oxygen carrying capacity of the bloodc. increase respiratory rated. increase oxygen pressure in the alveolar sac

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Answer: ARationale: Inadequate oxygen delivery to the body tissues may immediately predispose the client to hypoxia so the client needs oxygen therapy to increase oxygen in the tissues and cells.B, C, D are all secondary effects of oxygen therapy. Before these happen choice A should took place.(Source: Anatomy and physiology by E. Marieb, 398)

65. To promote lung expansions, what measure can the nurse employ?a. oxygen inhalation c. steam inhalationb. chest cupping d. deep breathing and coughing exercisesAnswer: DRationale: Deep breathing and coughing exercises help expand alveoli in the lungs, coughing removes secretions from the bronchi an d larger airways thereby facilitating greater expansion of the lungs. Encourage the client to perform deep breathing exercises before coughing to help assist in stimulating the cough reflex and mobilizing retained secretions (source: MS by Black, 6th ed., p. 286)A and C – are useful in promoting lung expansion; they require doctor’s order. Nurses should first employ nonpharmacologic interventions to promote lung expansion and should be independent functions.B-Loosens secretions in the lungs but still the client should cough out the secretions to promote better lung expansion

66. The ff. early manifestations of hypoxemia except:a. tachycardia c. tachypneab. restlessness d. cyanosisAnswer: DRationale: Cyanosis is a late and unreliable sign of hypoxemia. It does not occur unless reduced hemoglobin is more than 5g/100mL of capillary blood.A, B, C are all early signs of hypoxemia(Source:Pathophysiology 4th ed, Bullock, p. 600)

67. A 7 year old Filipino client has been diagnosed with leukemia. What intervention would be appropriate when considering the client’s culture?a. Ban all visits from alternative healers.b. Make diet selections for the child and family.c. Encourage visits from extended as well as immediate family.d. Limit all visitors, including extended family.ANSWER: B Rationale: To gain a client’s trust, respect may be conveyed even if there is disagreement with the belief expressed. Introductions and further assessment are important but ineffective if respect is not conveyed. Notifyng the physician does not have priority at this time. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p 131

68. A nurse is obtaining the pulse of a client and found the rate to be above normal. How would the nurse document this finding?a. Arrythmiab. Tachycardiac. Tachypnead. HyperpyrexiaAnswer: BRationale: Tachycardia is the correct terminology for an elevated heart rate. Tachypnea is an elevated respiratory rate. Arrythmia is an irregular rhythm of the heartbeat, and

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hyperpyrexia is a very elevated body temperature. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p 161

69. A night shift nurse has placed restraints on the following clients. In which situation would the use of restraints be appropriate?a. A client who is severely anxious about test results.b. A postoperative client who is alert but still weak.c. A child who is hyperactive.d. A child scratching the incision site postoperatively.ANSWER: D Rationale: One of the purposes of restraints should be to prevent interruption of therapy such as the use of dressings. Restraints should not be used for the convenience of the staff as in option c, nor should they be used because a client is weak or distraught (option b). The client in option a has no need for restraints. (Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p203

70. An elderly client is complaining of difficulty of passing out stool and asked the nurse why. What instruction should the nurse give?a. Decrease fluid intake.b. Avoid beverages with caffeine.c. Encourage bland and low residue foods. d. Drink hot liquids and fruit juices.ANSWER: DRationale: Instruct client to drink plenty of fluids, including fruit juices such as prune and apple to promote bowel function. In addition, foods that are high in fiber and roughage should be encouraged to avoid constipation .(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p203)

71. The nurse administered 20 units NPH insulin IV stat to a client who is diabetic as ordered by the physician. The patient had anaphylactoid reaction and died as a result of receiving the NPH insulin IV rather than subcutaneously, which is the only appropriate route. What liability is involved in this case?a. Only the physician is liable because the physician wrote the order.b. The nurse is legally liable for the medications administered even though the order was written incorrectly.c. The nurse is not legally liable because the nurse administered the medication as ordered by the physician.d. The nurse is not legally liable because the nurse gave the correct medication, regardless of the route.Answer: BRationale: Under the law, if a medication order is written incorrectly, the nurse who administers the incorrect order is responsible for the error. This includes both the right medication and the right dose( 2 of the 6”rights” of medication administration). The other options are incorrect. (Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p 337)

72. Diabetic Lara, 38 years old is readmitted to the hospital for evaluation of her condition. Which of these could be used to test for presence of sugar in the blood?a. Clinitest c. GTTb. Benedict’s test d. Tes-tapeAnswer: CRationale: Urine is tested for glucose to screen clients for diabetes mellitus or to follow progress of a known diabetic. Several commercial products are commonly used to test for the presence of glucose, for example, Clinitest tablets, and Clinistix, Diastix and Tes-

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tape reagent strips. Each uses a color scale to measure the quantity of glucose in the urine (source: FNP by Kozier, 5th ed., p. 1235)A, B, D are used to test for glucose in the urine

73. All but one blood exam requires fasting?a. CPK c. Sodium determinationb. Calcium determination d. Total bilirubinAnswer: A Rationale: An enzyme study like CPK does not require fasting before the test. Other test that don’t require fasting include CBC, Hgb, hematocrit level, clotting studies and serum electrolyte. In albumin globulin ratio the blood is drawn without fasting or special preparation. (source: MS by Black, 6th ed., p. 1082)B and C-Requires 8 hours of fasting before the test.D-Requires 4 hours of fasting before sampling(Source: Saunders comprehensive exam 2nd ed. p. 90-93)

74. Mang Roberto 68 years old complains of “gassy” abdomen. His AMD ordered rectal tube insertion. The nurse should insert the tube:a. 4-8 inches c. 2-4 inchesb. 8-10 inches d. 6-8 ichesAnswer: CRationale: Insert the tube 7 to 10 cm (3-4 inches). Because the anal canal is about 2.5 to 5 cm (1 to 2 in.) long in the adult, insertion to this point places the tip of the tube beyond the anal sphincter into the rectum.Source: Fundamentals of Nursing 7th Ed. by Kozier p.1243

75. Which of the ff. statement is true about rectal tube insertion?a. the rectal tube may remain the colon for 2-3 hours to achieve the desirable effectb. the rectal tube should remain the colon no longer than 30 minutes and reinserted 2-3 hours laterc. the rectal tube should remain in the colon only for 5-10 minutes to prevent damaged. the rectal tube may remain in the colon for 24 hours or until the effect has been achievedAnswer: BRationale: Insertion of rectal tube beyond 30 mins.will damage the rectal sphincter control.It is intermittently reinserted into 2-3 hours to achieve desirable effect.A, C, D are not applicable(Source: FNP by Kozier, 5th ed., p. 207)

76. Daniel, 50 years old has urinary incontinence. His urinary output for the past 3 hours is 60 ml. What should the nurse do?a. stimulate the patient to urinateb. palpate the patient’s hypogastrium c. position the patient o his leftd. inform the head nurse about the conditionAnswer: BRationale: The nurse should first assess if the client has a distended bladder by palpating the hypogastrium before doing options A and D.C-Position in Fowler’s, Flexes hips and knees.

77. Which of the ff. is the rationale for measuring fluid intake and output? To monitor:a. amount of fluid and electrolyte c. patient’s renal functionb. patient’s VS d. patient’s weight

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Answer: ARationale: The measurement and recording of fluid intake and output provides important data about the clients fluid electrolyte balanceB-Changes in VS may indicate fluid and electrolyte, acid base imbalances or compensating mechanisms for maintaining balanceC-Is the rationale for measuring hourly urine outputD-Can provide assessment of the client fluid status(Source: FNP by Kozier 7th ed., p.1067-1068)

78. Pain is one of the patient’s major problems. Which of the ff. statement is not true?a. utilize various types of pain relief measures if necessaryb. utilize measures that the nurse believes to be effectivec. if therapy proves ineffective at first, change with another relief measured. pain tolerance varies greatly among individuals Answer: BRationale: Use pain-relieving measures that the CLIENT believes are effective. It has been recognized that clients are usually the authorities on their own pain. Thus, incorporating the clients’ measures in to a pain relief plan is sensible unless they are harmful.A-It is thought that using more than one measure has an additive effect in relieving pain. Because client’s pain may vary throughout a 24-hour period, different types of pain relief are often during that time.C-Sometimes strategies need to be tried and changed until the client obtains effective pain relief.D – is true(Source: FNP by Kozier, 5th ed., p. 994)

79. Heat and cold application can relieve pain. The application of cold gives the primary effects of:1. vasoconstriction a. 1,22. vasodilation b. 1,43. tissue damage c. 2,34. slowed metabolism d. 1,3Answer: BRationale: These are both physiologic effects of cold applications to relieve pain. Cold has a vasodilating effect. Tissue damage could occur if either heat or cold is applied beyond 30 minutes.Cold application in general is safer than heat. It is done during the first 24 hours; heat application follows after 24 hours. Heat application usually requires doctor’s orderDuring heat and cold application, check the area every 15 to 20 minutes. Increased pain and swelling, numbness, extreme redness and mottling may indicate the need to discontinue the treatment.(Source: FNP by Udan, yr 2001, p.34)

80. The most dangerous complication of vomiting is:a. aspiration c. hypokalemiab. dehydration d. feverAnswer: ARationale: After aspiration, respiratory distress usually begins abruptly with evidence of bronchospasm, dyspnea, tachycardia and cyanosis. Severe hypoxemia frequently occurs and may precipitate adult respiratory syndrome(ARDS )(source: pathophysiology by Bullock 4th ed. p. 576)B and C would not occur abruptly as aspiration and are not serious complication of vomiting.D- Is the stimulus to vomiting not a complication or effect.

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81. The ff. appropriate nsg. Interventions to relieve anorexia, except:a. provide fastidious hygiene c. serve food at proper temperatureb. offer small, frequent feedings d. administer vitamin substituteAnswer: DRationale: Administering vitamins substitute food is not enough to replace the fluid and electrolytes lost and to increase weight.B- offering small frequent meal promotes weight gainA and C- Increase appetite

82. Which statement as heard by the nurse during intershift report provides the most useful information related to priority setting for the next shift?a. A client admitted for congestive heart failure has a blood pressure of 138/80.b. A client who had catheter removed 8 hours ago has not urinated.c. A client who is 3 days postoperative is experiencing incisional pain.d. A client who is alert and oriented to person and place.Answer: BRationale: A client who has not urinated following catheter removal would require nursing intervention, specifically an assessment of the client’s abdominal distention, reviewing intake and output records, possibly calling the physician for an order to do a straight catheterization. The second priority would be the client who has incisional pain however, since the client is 3 days postoperative, this is not an urgent problem as option B. The information contained in A and B pose no threats to the health status of those clients. (Source: Hogan NURSING FUNDAMENTALS Reviews and Rationales p87) 83. What nursing diagnosis would most likely be appropriate for the absence of hair on a 72 year old male client’s legs?a. Risk for infectionb. Tissue perfusion, altered: peripheralc. Fluid volume deficitd. Altered nutrition: less than body requirementsAnswer: BRationale: During physical assessment, the nurse inspects the client’s legs for hair distribution. The most common reason for shiny skin and a complete absence of hair is poor circulation related to peripheral vascular disease (PVD). The other nursing diagnosis should not affect air distribution. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p63

84. Prior to inserting an Otoscope to a male, adult client, what should the nurse do to adequately inspect the external ear canal? a. Have the client lie down to promote comfort.b. Pull the pinna up and back.c. Require that all earrings be removed for safety purposes.d. Use an applicator to remove the cerumen.Answer: BRationale: In order to facilitate visualization of the ear canal and tympanic membrane, the pinna should be pulled up and back for an adult client. If earrings are attached to the lobe, there should not be a safety issue; however, they may be removed if they are large in size or cause the client discomfort during the examination. The nurse should not remove cerumen with an applicator because of the risk of pushing it further into the canal or rupturing the tympanic membrane. Generally, the ear and eye physical assessment are performed with the client sitting upright. Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p 63

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85. While on her way home, a nurse stops and provides first aid to a motor vehicle accident. The nurse knows that this action is protected by the Good Samaritan law. Which statement about Good Samaritan law is correct?a. It does not provide liability for the nurse responding to an emergency.b. It hinders nurses from providing help during an accident.c. It was created specifically for RN’s and LPN’s.d. It differs from state to state.Answer: DRationale: It differs from state to state and should be reviewed by the practicing RN. Good Samaritan laws are designed to protect healthcare professionals who offer assistance during an emergency and may apply to various licensed personnel. . (Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p104)

86. Which of the following activities by the nurse is an example of health promotion? a. giving a bath b. preventing incidents in the home c. administering immunizations d. performing diagnostic proceduresAnswer: BRationale: Nurses promote wellness in clients who are both healthy and ill. This may involve individual and community activities to enhance healthy lifestyles, such as improving nutrition and physical fitness , preventing drug and alcohol misuse, restricting smoking and preventing accidents and injury in the home and workplace. (Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 8)

87. What can be best described as a set of shared understandings and assumptions about reality and the world?a. conceptb. practice disciplinec. conceptual frameworkd. paradigm Answer: DRationale: PARADIGM refers to a pattern of shared understandings and assumptions about reality and the world. (Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 36)

88. Which of the following is not true of adaptation?a. adaptation is basically protectiveb. it involves alteration in the body structure or functionc. it seeks to prevent stressors from acting on the bodyd. it includes all dynamic processes to maintain balanceAnswer: CRationale: Adaptation is a process of change in response to stress.A, B, D – are t rueA-a resistance to stressB -it denotes interaction and changeD - basis of homeostasis(source: FNP by Udan, yr 2001, p.81)

89. Which is the most important nursing responsibility in patient care ethical situations?a. To be able to defend the morality of one’s own actions.b. To make sure that the team is responsible for deciding ethical questions.

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c. Follow exactly what the family wishes.d. To remain neutral and detached in ethical decisions.Answer: B Rationale: Although the nurse’s input is important, in reality several people are usually involved in making an ethical decision. Therefore, collaboration, communication,and compromise are important skills for health professionals. When nurses do not have autonomy to act on their moral or ethical choices,compromise becomes essential. Kozier FUNDAMENTALS OF NURSING 7th Edition p77

90. Which statement is appropriate in initiating care to a client of a different culture than the nurse?a. “Do you have any books I could read about people of your culture?”b. “Since, in your culture, people don’t drink ice water, I will bring you hot tea.”c. “Please let me know if I do anything that is not acceptable in your culture.”d. “You have to set aside your usual customs and practices while you are in this hospital.”Answer: CRationale: All phases of the nursing process are affected by the client’s cultural values, beliefs, and behaviors. As the client’s culture and the nurse’s culture come together in the nurse-client relationship, a unique cultural environment is created that can improve or impair the client’s outcome. Self awareness of personal biases can enable nurses to develop modifying behaviors or (if they are unable to do so) to remove themselves from situations where care may be compromised.(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 215)

91. In using the three part diagnostic statement in the PES format , which is correct?a. The three part diagnostic statement is always more accurate.b. The three part diagnostic statement is shorter.c. The three part diagnostic statement applies to risk and wellness diagnoses also.d. The three part diagnostic statement documents the indicators of the problem. Answer: D Rationale: The three part diagnostic statement documents the indicators of the problem.(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 217)

92. The skill of attentive listening by the nurse requires ?a. absorbing both the content and the feeling the person is conveying without selectivity.b. Total relaxation by the listening nurse.c. Assuming what needs the client has.d. Adopting a closed professional posture.Answer: ARationale: Attentive listening is listening actively, using all the senses, as opposed to listening passively with just one ear. It is probably the most important technique in nursing and is basic to all other techniques. Attentive listening is an active process that requires energy and concentration. It involves paying attention to the total message, both verbal and non verbal, and noting whether these communications are congruent. Attentive listening means absorbing both the content and the feeling the person is conveying, without selectivity.The listener does not select or listen solely to what the listener wants to hear; the nurse focuses not on the nurse’s own needs but rather on the client’s needs. Attentive listening conveys an attitude of caring and interest, thereby encouraging the client to talk. (Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 429)

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93. A client in pain is struggling with cancer. The nurse points out “It is normal to feel frustrated about the discomfort.” What skill in the working phase of the helping relationship is the nurse using?a. confrontationb. concretenessc .respectd. genuinenessAnswer: D genuineness(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 323)

94. Which of the following nursing diagnosis is appropriate to a 50 year old depressed patient who hasn’t taken a bath nor changed her clothes? She is just seated with her food tray unable to make a decision about having her lunch .a. Powerlessnessb. Anxietyc. Chronic Low Self Esteemd. Social IsolationAnswer: A(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 365)

95. An initial assessment was done to a responsive and alert client admitted directly from the doctor’s office diagnosed to rule out infarction (MI). Which of the following alterations is of greatest concern to the nurse?a. Respirations are 28 and laboredb. Temperature is 99.8Fc. Blood pressure supine is 138/76.d. There are frequent missed apical beats.Answer: ARationale: Using the ABC principles (Airway, Breathing, Circulation), an alteration in respiration is always a primary concern. A disturbance in normal ventilation is occurring secondary to the medical diagnosis of myocardial infarction. The blood pressure remains in acceptable range, and the temperature elevation is likely related to the overall inflammatory response of the body. Infrequent abnormalities of cardiac rhythm are common and should be of concern only when appearing regularly or with longer duration. (Source: Hogan NURSING FUNDAMENTALS Reviews and Rationales p62)

96. A widely used method of organizing and recording data about a client which is quickly accessible to all members of the health team, usually during endorsement procedure is:a. Kardex c. SORb. POR d. ComputerAnswer: ARationale: B-in problem oriented medical record, data about the client are recorded and arranged according to the source of the info. The record integrates all data about a problem, gathered by the members of the health team. Four basic components: (1.) data base, (2) problem list, (3) initial list of orders or care plans, and (4) progress notes which includes nurse’s or narrative notes, flow sheets and discharge notes or referral summariesC- in source oriented medical record, each person or department makes notations in a separate section/s of the client’s chart. Also called traditional client record. Five components are: (1) admission sheet; (2) physician’s order sheet; (3) medical history sheet; (4) nurses notes; and (5) special records and reports (e.g. referrals, X-ray report, lab. findings)

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D- currently, nurses use computers to assist with practice in clinical settings. In a hospital setting, computers are used by nurses to: enter orders and retrieve results from various ancillary departments, document client progress using critical pathways or other methodologies, track medication administration and enter client assessments(source: FNP by Taylor, p. 230)(source: FNP by Udan, yr 2001, p.52-53)

97. Which of the following is not caused by prolonged immobility?a. contractures c. pneumoniab. thrombosis d. incontinenceAnswer: DRationale: Urinary incontinence possible etiology are external urinary sphincter injury, obstetric injury, lesions of bladder neck, detrusor dysfunction, infection, neurogenic bladder, medications, neurologicc abnormalities

98. Which of the following lab results indicate normal serum K?a. 3.0 mEq/L c. 4.0 mEq/Lb. 2.0 mEq/L d. 6.0 mEq/L Answer: CRationale: Normal seum K+ ranges from 3.5- 5.0 mEq/L(Source: MS by Udan, yr 2002., p. 265)

99. All but one are roentgenogram examinations:a.IVP c. EMGb. Barium enema d. UGISAnswer: CRationale: EMG records electrical activity arising from the muscle-associated muscular activity after nerve stimulation with an electrical current.B- roentgenogram of the colonD- roentgenogram of the esophagus and colonA- roentgenogram of kidney, urinary tract and bladder(source: FNP by Udan, yr 2001, p.267-268)

100. All but one is true of GAS?a. adaptation basically is protectiveb. it is a sequence of behavior involving the whole bodyc. it is an abnormal alteration in body function due to stressd. it is essentially a neuroendocrine responseAnswer: CRationale: It’s a normal alteration in body function due to stressB- man whenever he responds to stress, the entire body is involvedD- The GAS occurs with the release of certain adaptive hormones and subsequent changes in the structure and chemical composition of the bodyStages of GAS:

I. stage of alarm – the person becomes aware of the presence of threat or danger; levels or resistance are decreased; adaptive mechanisms are mobilized (fight-or-flight reaction); if the stress is intense enough, even at the stage of alarm, death may ensue.

II. stage of resistance- characterized by adaptation; levels of resistance are increased; the person moves back to homeostasisIII. stage of exhaustion- results from prolonged exposure to stress and adaptive mechanisms can no longer persist; unless other adaptive mechanisms will be mobilized, death may ensue.

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(source: FNP by Udan, yr 2001, p.26)

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