Fundamentals of Nursing (2) - 100 Items - Answers and Rationale

8/8/2019 Fundamentals of Nursing (2) - 100 Items - Answers and Rationale

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Fundamentals Of Nursing : Infection, Asepsis, Basic concept of stress and Illness

Correct Answers and Rationales

Fundamentals Of Nursing : Infection, Asepsis, Basic concept of stress and IllnessBy : Budekhttp://www.pinoybsn.tk

FUNDAMENTALS OF NURSING TEST II

CONTENT OUTLINE

1. Illness

2. Infection and Asepsis3. Basic concept of Stress and Adaptation

1. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in.Sympathetic nervous system releases norepinephrine while the adrenal medulla secretesepinephrine. Which of the following is true with regards to that statement?

A. Pupils will constrictB. Client will be lethargicC. Lungs w ill bronchodilateD. Gastric motility will increase

* To better understand the concept : The autonomic nervous system is composed of

SYMPATHETIC and PARASYMPATHETIC Nervous system. It is called AUTONOMIC Because itis Involuntary and stimuli based. You cannot tell your heart to kindly beat for 60 per

minute, Nor, Tell your blood vessels, Please constrict, because you need to wear skirt todayand your varicosities are bulging. Sympathetic Nervous system is the FIGHT or FLIGHTmechanism. When people FIGHT or RUN, we tend to stimulate the ANS and dominate over

SNS. Just Imagine a person FIGHTING and RUNNING to get the idea on the signs of SNSDomination. Imagine a resting and digesting person to get a picture of PNS Domination. Aperson RUNNING or FIGHTING Needs to bronchodilate, because the oxygen need isincreased due to higher demand of the body. Pupils will DILATE to be able to see the enemy

clearly. Client will be fully alert to dodge attacks and leap through obstacles during running.The client's gastric motility will DECREASE Because you cannot afford to urinate or defecateduring fighting nor running.2. Which of the following response is not expected to a person whose GAS is activated andthe FIGHT OR FLIGHT response sets in?

A. The client will not urinate due to relaxation of the detrusor muscle

B. The client will be restless and alertC. Clients BP w ill increase, there w ill be vasodilation

D. There will be increase glycogenolysis, Pancrease will decrease insulin secretion

* If vasodilation will occur, The BP will not increase but decrease. It is true that Bloodpressure increases during SNS Stimulation due to the fact that we need more BLOOD tocirculate during the FIGHT or FLIGHT Response because the oxygen demand has increased,but this is facilitated by vasoconstriction and not vasodilation. A,B and D are all correct. Theliver will increase glycogenolysis or glycogen store utilization due to a heightened demandfor energy. Pancrease will decrease insulin secretion because almost every aspect ofdigestion that is controlled by Parasympathetic nervous system is inhibited when the SNS

dominates.

3. State in which a persons physical, emotional, intellectual and social development orspiritual functioning is diminished or impaired compared with a previous experience.


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A. IllnessB. DiseaseC. Health

D. Wellness

* Disease is a PROVEN FACT based on a medical theory, standards, diagnosis and clinicalfeature while ILLNESS Is a subjective state of not feeling well based on subjective appraisal,

previous experience, peer advice etc.

4. This is the first stage of illness wherein, the person starts to believe that something is

wrong. Also known as the transition phase from wellness to illness.

A. Symptom ExperienceB. Assumption of sick roleC. Medical care contactD. Dependent patient role

* A favorite board question are Stages of Illness. When a person starts to believesomething is wrong, that person is experiencing signs and symptoms of an illness. The

patient will then ASSUME that he is sick. This is called assumption of the sick role where thepatient accepts he is Ill and try to give up some activities. Since the client only ASSUMEShis illness, he will try to ask someone to validate if what he is experiencing is a disease, Thisis now called as MEDICAL CARE CONTACT. The client seeks professional advice forvalidation, reassurance, clarification and explanation of the symptoms he is experiencing.client will then start his dependent patient role of receiving care from the health careproviders. The last stage of Illness is the RECOVERY stage where the patient gives up thesick role and assumes the previous normal gunctions.

5. In this stage of illness, the person accepts or rejects a professionals suggestion. Theperson also becomes passive and may regress to an earlier stage.

A. Symptom ExperienceB. Assumption of sick roleC. Medical care contactD. Dependent patient ro le

* In the dependent patient role stage, Client needs professionals for help. They have a

choice either to accept or reject the professional's decisions but patients are usually passiveand accepting. Regression tends to occur more in this period.

6. In this stage of illness, The person learns to accept the illness.

A. Symptom ExperienceB. Assumption of sick role

C. Medical care contactD. Dependent patient role

* Acceptance of illness occurs in the Assumption of sick role phase of illness.

7. In this stage, the person tries to find answers for his illness. He wants his illness to bevalidated, his symptoms explained and the outcome reassured or predicted

A. Symptom ExperienceB. Assumption of sick role

C. Medical care contactD. Dependent patient role

* At this stage, The patient seeks for validation of his symptom experience. He wants tofind out if what he feels are normal or not normal. He wants someone to explain why is he


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feeling these signs and symptoms and wants to know the probable outcome of thisexperience.

8. The following are true with regards to aspect of the sick role except

A. One should be held responsible for his conditionB. One is excused from his societal role

C. One is obliged to get well as soon as possibleD. One is obliged to seek competent help

* The nurse should not judge the patient and not view the patient as the cause or someoneresponsible for his illness. A sick client is excused from his societal roles, Oblige to get well

as soon as possible and Obliged to seek competent help.

9. Refers to conditions that increases vulnerability of individual or group to illness oraccident

A. Predisposing factorB. Etiology

C. Risk fac torD. Modifiable Risks

10. Refers to the degree of resistance the potential host has against a certain pathogen

A. SusceptibilityB. ImmunityC. VirulenceD. Etiology

* Immunity is the ABSOLUTE Resistance to a pathogen considering that person has anINTACT IMMUNITY while susceptibility is the DEGREE of resistance. Degree of resistancemeans how well would the individual combat the pathogens and repel infection or invasionof these disease causing organisms. A susceptible person is someone who has a very lowdegree of resistance to combat pathogens. An Immune person is someone that can easilyrepel specific pathogens. However, Remember that even if a person is IMMUNE [Vaccination ] Immunity can always be impaired in cases of chemotherapy, HIV, Burns, etc.

11. A group of symptoms that sums up or constitute a disease

A. SyndromeB. SymptomsC. SignsD. Etiology

* Symptoms are individual manifestation of a certain disease. For example, In Tourettesyndrome, patient will manifest TICS, but this alone is not enough to diagnose the patientas other diseases has the same tic manifestation. Syndrome means COLLECTION of thesesymptoms that occurs together to characterize a certain disease. Tics with coprolalia,echolalia, palilalia, choreas or other movement disorders are characteristics of TOURETTESYNDROME.

12. A woman undergoing radiation therapy developed redness and burning of the skinaround the best. This is best classified as what type of disease?

A. NeoplasticB. Traumatic

C. NosocomialD. Iatrogenic


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* Iatrogenic diseases refers to those that resulted from treatment of a certain disease. Forexample, A child frequently exposed to the X-RAY Machine develops redness and partialthickness burns over the chest area. Neoplastic are malignant diseases cause by

proliferation of abnormally growing cells. Traumatic are brought about by injuries like Motorvehicular accidents. Nosocomial are infections that acquired INSIDE the hospital. Example isUTI Because of catheterization, This is commonly caused by E.Coli.

13. The classification of CANCER according to its etiology Is best described as

1. Nosocomial

2. Idiopathic3. Neoplastic

4. Traumatic5. Congenital6. Degenrative

A. 5 and 2B. 2 and 3C. 3 and 4

D. 3 and 5

* Aside from being NEOPLASTIC, Cancer is considered as IDIOPATHIC because the cause isUNKNOWN.

14. Term to describe the reactiviation and recurrence of pronounced symptoms of a disease

A. RemissionB. Emission

C. ExacerbationD. Sub acute

15. A type of illness characterized by periods of remission and exacerbation

A. ChronicB. AcuteC. Sub acuteD. Sub chronic

* A good example is Multiple sclerosis that characterized by periods of remissions andexacerbation and it is a CHRONIC Disease. An acute and sub acute diseases occurs tooshort to manifest remissions. Chronic diseases persists longer than 6 months that is whyremissions and exacerbation are observable.

16. Diseases that results from changes in the normal structure, from recognizable

anatomical changes in an organ or body tissue is termed as

A. FunctionalB. OccupationalC. InorganicD. Organic

* As the word implies, ORGANIC Diseases are those that causes a CHANGE in the structureof the organs and systems. Inorganic diseases is synonymous with FUNCTIONAL diseaseswherein, There is no evident structural, anatomical or physical change in the structure of

the organ or system but function is altered due to other causes, which is usually due toabnormal response of the organ to stressors. Therefore, ORGANIC BRAIN SYNDROME are

anatomic and physiologic change in the BRAIN that is NON PROGRESSIVE BUTIRREVERSIBLE caused by alteration in structure of the brain and it's supporting structurewhich manifests different sign and symptoms of neurological, physiologic and psychologic


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alterations. Mental disorders manifesting symptoms of psychoses without any evidentorganic or structural damage are termed as INORGANIC PSYCHOSES while alteration in theorgan structures that causes symptoms of bizaare pyschotic behavior is termed as ORGANIC

PSYCHOSES.

17. It is the science of organism as affected by factors in their environment. It deals withthe relationship between disease and geographical environment.

A. EpidemiologyB. Ecology

C. StatisticsD. Geography

* Ecology is the science that deals with the ECOSYSTEM and its effects on living things inthe biosphere. It deals with diseases in relationship with the environment. Epidimiology issimply the Study of diseases and its occurence and distribution in man for the purpose ofcontrolling and preventing diseases. This was asked during the previous boards.

18. This is the study of the patterns of health and disease. Its occurrence and distribution in

man, for the purpose of control and prevention of disease.

A. EpidemiologyB. EcologyC. StatisticsD. Geography

* Refer to number 17.

19. Refers to diseases that produced no anatomic changes but as a result from abnormalresponse to a stimuli.

A. FunctionalB. OccupationalC. InorganicD. Organic

* Refer to number 16.

20. In what level of prevention according to Leavell and Clark does the nurse support theclient in obtaining OPTIMAL HEALTH STATUS after a disease or injury?

A. PrimaryB. SecondaryC. Tertiary

D. None of the above

* Perhaps one of the easiest concept but asked frequently in the NLE. Primary refers topreventions that aims in preventing the disease. Examples are healthy lifestyle, goodnutrition, knowledge seeking behaviors etc. Secondary prevention are those that deals withearly diagnostics, case finding and treatments. Examples are monthly breast self exam,Chest X-RAY, Antibiotic treatment to cure infection, Iron therapy to treat anemia etc.Tertiary prevention aims on maintaining optimum level of functioning during or after theimpact of a disease that threatens to alter the normal body functioning. Examples areprosthetis fitting for an amputated leg after an accident, Self monitoring of glucose among

diabetics, TPA Therapy after stroke etc.

The confusing part is between the treatment in secondary and treatment in tertiary. To bestdifferentiate the two, A client with ANEMIA that is being treated with ferrous sulfate isconsidered being in the SECONDARY PREVENTION because ANEMIA once treated, will move


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the client on PRE ILLNESS STATE again. However, In cases of ASPIRING Therapy in cases ofstroke, ASPIRING no longer cure the patient or PUT HIM IN THE PRE ILLNESS STATE. ASAtherapy is done in order to prevent coagulation of the blood that can lead to thrombus

formation and a another possible stroke. You might wonder why I spelled ASPIRIN asASPIRING, Its side effect is OTOTOXICITY [ CN VIII ] that leads to TINNITUS or ringing ofthe ears.

21. In what level of prevention does the nurse encourage optimal health and increasespersons susceptibility to illness?

A. PrimaryB. Secondary

C. TertiaryD. None of the above

* The nurse never increases the person's susceptibility to illness but rather, LESSEN theperson's susceptibility to illness.

22. Also known as HEALTH MAINTENANCE prevention.

A. PrimaryB. SecondaryC. TertiaryD. None of the above

* Secondary prevention is also known as HEALTH MAINTENANCE Prevention. Here, Theperson feels signs and symptoms and seeks Diagnosis and treatment in order to preventdeblitating complications. Even if the person feels healthy, We are required to MAINTAIN

our health by monthly check ups, Physical examinations, Diagnostics etc.

23. PPD In occupational health nursing is what type of prevention?

A. PrimaryB. SecondaryC. TertiaryD. None of the above

* PPD or PERSONAL PROTECTIVE DEVICES are worn by the workes in a hazardousenvironment to protect them from injuries and hazards. This is considered as a PRIMARYprevention because the nurse prevents occurence of diseases and injuries.

24. BCG in community health nursing is what type of prevention?

A. Primary

B. SecondaryC. TertiaryD. None of the above

25. A regular pap smear for woman every 3 years after establishing normal pap smear for 3consecutive years Is advocated. What level of prevention does this belongs?

A. PrimaryB. SecondaryC. Tertiary

D. None of the above

26. Self monitoring of blood glucose for diabetic clients is on what level of prevention?

A. Primary


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B. SecondaryC. TertiaryD. None of the above

27. Which is the best way to disseminate information to the public?

A. Newspaper

B. School bulletinsC. Community bill boardsD. Radio and Television

* An actual board question, The best way to disseminate information to the public is by

TELEVISION followed by RADIO. This is how the DOH establish its IEC Programs other thanpublising posters, leaflets and brochures. An emerging new way to disseminate is throughthe internet.

28. Who conceptualized health as integration of parts and subparts of an individual?

A. Newman

B. NeumanC. WatsonD. Rogers

* The supra and subsystems are theories of Martha Rogers but the parts and subparts areBetty Neuman's. She stated that HEALTH is a state where in all parts and subparts of anindividual are in harmony with the whole system. Margarex Newman defined health as anEXPANDING CONSCIOUSNESS. Her name is Margaret not Margarex, I just used that to helpyou remember her theory of health.

29. The following are concept of health:

1. Health is a state of complete physical, mental and social wellbeing and not merely anabsence of disease or infirmity.2. Health is the ability to maintain balance3. Health is the ability to maintain internal milieu4. Health is integration of all parts and subparts of an individual

A. 1,2,3B. 1,3,4C. 2,3,4D. 1,2,3,4

* All of the following are correct statement about health. The first one is the definition byWHO, The second one is from Walter Cannon's homeostasis theory. Third one is from

Claude Bernard's concept of Health as Internal Milieu and the last one is Neuman's Theory.

30. The theorist the advocated that health is the ability to maintain dynamic equilibrium is

A. BernardB. SelyeC. CannonD. Rogers

* Walter Cannon advocated health as HOMEOSTASIS or the ability to maintain dynamic

equilibrium. Hans Selye postulated Concepts about Stress and Adaptation. Bernard definedhealth as the ability to maintain internal milieu and Rogers defined Health as Wellness that

is influenced by individual's culture.

31. Excessive alcohol intake is what type of risk factor?


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A. GeneticsB. Age

C. EnvironmentD. Lifestyle

32. Osteoporosis and degenerative diseases like Osteoarthritis belongs to what type of risk

factor?

A. Genetics

B. AgeC. Environment

D. Lifestyle

33. Also known as STERILE TECHNIQUE

A. Surgical AsepsisB. Medical AsepsisC. Sepsis

D. Asepsis

* Surgical Asepsis is also known as STERILE TECHNIQUE while Medical Asepsis issynonymous with CLEAN TECHNIQUE.

34. This is a person or animal, who is without signs of illness but harbors pathogen withinhis body and can be transferred to another

A. Host

B. AgentC. EnvironmentD. Carrier

35. Refers to a person or animal, known or believed to have been exposed to a disease.

A. CarrierB. ContactC. Agent

D. Host

36. A substance usually intended for use on inanimate objects, that destroys pathogens butnot the spores.

A. SterilizationB. Disinfectant

C. AntisepticD. Autoclave

* Disinfectants are used on inanimate objects while Antiseptics are intended for use onpersons and other living things. Both can kill and inhibit growth of microorganism butcannot kill their spores. That is when autoclaving or steam under pressure gets in,Autoclaving can kill almost ALL type of microoganism including their spores.

37. This is a process of removing pathogens but not their spores

A. SterilizationB. Auto claving

C. DisinfectionD. Medical asepsis


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* Both A and B are capable on killing spores. Autoclaving is a form of Sterilization. MedicalAsepsis is a PRACTICE designed to minimize or reduce the transfer of pathogens, alsoknown as your CLEAN TECHNIQUE. Disinfection is the PROCESS of removing pathogens but

not their spores.

38. The third period of infectious processes characterized by development of specific signsand symptoms

A. Incubation periodB. Prodromal period

C. Illness periodD. Convalescent period

* In incubation period, The disease has been introduced to the body but no sign andsymptom appear because the pathogen is not yet strong enough to cause it and may stillneed to multiply. The second period is called prodromal period. This is when the appearanceof non specific signs and symptoms sets in, This is when the sign and symptoms starts toappear. Illness period is characterized by the appearance of specific signs and symptoms orrefer tp as time with the greatest symptom experience. Acme is the PEAK of illness intensity

while the convalescent period is characterized by the abatement of the disease process orit's gradual disappearance.

39. A child with measles developed fever and general weakness after being exposed toanother child with rubella. In what stage of infectious process does this child belongs?

A. Incubation periodB. Prodromal periodC. Illness period

D. Convalescent period

* To be able to categorize MEASLES in the Illness period, the specific signs of Fever,Koplik's Spot and Rashes must appear. In the situation above, Only general signs andsymptoms appeared and the Specific signs and symptoms is yet to appear, therefore, theillness is still in the Prodromal period. Signs and symptoms of measles during the prodromalphase are Fever, fatigue, runny nose, cough and conjunctivitis. Koplik's spot heralds theIllness period and cough is the last symptom to disappear. All of this processes take place in10 days that is why, Measles is also known as 10 day measles.

40. A 50 year old mailman carried a mail with anthrax powder in it. A minute afterexposure, he still hasnt developed any signs and symptoms of anthrax. In what stage ofinfectious process does this man belongs?

A. Incubation periodB. Prodromal period

C. Illness periodD. Convalescent period

* Anthrax can have an incubation period of hours to 7 days with an average of 48 hours.Since the question stated exposure, we can now assume that the mailman is in theincubation period.

41. Considered as the WEAKEST LINK in the chain of infection that nurses can manipulate toprevent spread of infection and diseases

A. Etiologic/Infectious agentB. Portal of Entry

C. Susceptible hostD. Mode of transmission


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* Mode of transmission is the weakest link in the chain of infection. It is easily manipulatedby the Nurses using the tiers of prevention, either by instituting transmission basedprecautions, Universal precaution or Isolation techniques.

42. Which of the following is the exact order of the infection chain?

1. Susceptible host

2. Portal of entry3. Portal of exit4. Etiologic agent

5. Reservoir6. Mode of transmission

A. 1,2,3,4,5,6B. 5,4,2,3,6,1C. 4,5,3,6,2,1D. 6,5,4,3,2,1

* Chain of infection starts with the SOURCE : The etiologic agent itself. It will first

proliferate on a RESERVOIR and will need a PORTAL OF EXIT to be able to TRANSMIT irslefusing a PORTAL OF ENTRY to a SUSCEPTIBLE HOST. A simple way to understand theprocess is by looking at the lives of a young queen ant that is starting to build her colony.Imagine the QUEEN ANT as a SOURCE or the ETIOLOGIC AGENT. She first need to build aCOLONY, OR the RESERVOIR where she will start to lay the first eggs to be able to produceher worker ants and soldier ants to be able to defend and sustain the new colony. Theyneed to EXIT [PORTAL OF EXIT] their colony and crawl [MODE OF TRANSMISSION] insearch of foods by ENTERING / INVADING [PORTAL OF ENTRY] our HOUSE [SUSCEPTIBLEHOST]. By imagining the Ant's life cycle, we can easily arrange the chain of infection.

43. Markee, A 15 year old high school student asked you. What is the mode of transmissionof Lyme disease. You correctly answered him that Lyme disease is transmitted via

A. Direct contact transmissionB. Vehicle borne transmissionC. Air borne transmissionD. Vector borne transmission

* Lyme disease is caused by Borrelia Burdorferi and is transmitted by a TICK BITE.

44. The ability of the infectious agent to cause a disease primarily depends on all of thefollowing except

A. PathogenicityB. Virulence

C. InvasivenessD. Non Specificity

* To be able to cause a disease, A pathogen should have a TARGET ORGAN/S. Thepathogen should be specific to these organs to cause an infection. Mycobacterium Avium isNON SPECIFIC to human organs and therefore, not infective to humans but deadly to birds.An immunocompromised individual, specially AIDS Patient, could be infected with theseNON SPECIFIC diseases due to impaired immune system.

45. Contact transmission of infectious organism in the hospital is usually cause by

A. Urinary catheterization

B. Spread from patient to patientC. Spread by cross contamination via hands o f caregiverD. Cause by unclean instruments used by doctors and nurses


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* The hands of the caregiver like nurses, is the main cause of cross contamination inhospital setting. That is why HANDWASHING is the single most important procedure to

prevent the occurence of cross contamination and nosocomial infection. D refers toNosocomial infection and UTI is the most common noscomial infection in the hospital causedby urinary catheterization. E.Coli seems to be the major cause of this incident. B best fitsCross Contamination, It is the spread of microogranisms from patient o patient.

46. Transmission occurs when an infected person sneezes, coughs or laugh that is usuallyprojected at a distance of 3 feet.

A. Droplet transmission

B. Airborne transmissionC. Vehicle transmissionD. Vector borne transmission

47. Considered as the first line of defense of the body against infection

A. Skin

B. WBCC. LeukocytesD. Immunization

* Remember that intact skin and mucus membrane is our first line of defense againstinfection.

48. All of the following contributes to host susceptibility except

A. CreedB. ImmunizationC. Current medication being takenD. Color of the skin

* Creed, Faith or religious belief do not affect person's susceptibility to illness. Medicationlike corticosteroids could supress a person's immune system that will lead to increasesusceptibility. Color of the skin could affect person's susceptibility to certain skin diseases. Adark skinned person has lower risk of skin cancer than a fair skinned person. Fair skinned

person also has a higher risk for cholecystitis and cholelithiasis.

49. Graciel has been injected TT5, her last dosed for tetanus toxoid immunization. Gracielasked you, what type of immunity is TT Injections? You correctly answer her by sayingTetanus toxoid immunization is a/an

A. Natural active immunity

B. Natural passive immunityC. Artificial active immunityD. Artificial passive immunity

* TT1 ti TT2 are considered the primary dose, while TT3 to TT5 are the booster dose. Awoman with completed immunization of DPT need not receive TT1 and TT2. Tetanus toxoidis the actual toxin produce by clostridium tetani but on its WEAK and INACTIVATED form. Itis Artificial because it did not occur in the course of actual illness or infection, it is Activebecause what has been passed is an actual toxin and not a ready made immunoglobulin.

50. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway.She suffered multiple injuries and was injected Tetanus toxoid Immunoglobulin. Agatha

asked you, What immunity does TTIg provides? You best answered her by saying TTIgprovides


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A. Natural active immunityB. Natural passive immunityC. Artificial active immunity

D. Artificial passive immunity

* In this scenario, Agatha was already wounded and has injuries. Giving the toxin [TTVaccine] itself would not help Agatha because it will take time before the immune system

produce antitoxin. What agatha needs now is a ready made anti toxin in the form of ATS orTTIg. This is artificial, because the body of agatha did not produce it. It is passive becauseher immune system is not stimulated but rather, a ready made Immune globulin is given to

immediately supress the invasion.

51. This is the single most important procedure that prevents cross contamination andinfection

A. CleaningB. DisinfectingC. SterilizingD. Handwashing

* When you see the word HANDWASHING as one of the options, 90% Chance it is thecorrect answer in the local board. Or should I say, 100% because I have yet to see questionfrom 1988 to 2005 board questions that has option HANDWASHING on it but is not thecorrect answer.

52. This is considered as the most important aspect of handwashing

A. Time

B. FrictionC. WaterD. Soap

* The most important aspect of handwashing is FRICTION. The rest, will just enhancefriction. The use of soap lowers the surface tension thereby increasing the effectiveness offriction. Water helps remove transient bacteria by working with soap to create the latherthat reduces surface tension. Time is of essence but friction is the most essential aspect ofhandwashing.

53. In handwashing by medical asepsis, Hands are held .

A. Above the elbow, The hands must always be above the waistB. Above the elbow, The hands are cleaner than the elbowC. Below the elbow, Medical asepsis do not require hands to be above the waistD. Below the elbow, Hands are dirtier than the low er arms

* Hands are held BELOW the elbow in medical asepsis in contrast with surgical asepsis,wherein, nurses are required to keep the hands above the waist. The rationale is because inmedical asepsis, Hands are considered dirtier than the elbow and therefore, to limitcontamination of the lower arm, The hands should always be below the elbow.

54. The suggested time per hand on handwashing using the time method is

A. 5 to 10 seconds each handB. 10 to 15 seconds each hand

C. 15 to 30 seconds each handD. 30 to 60 seconds each hand

* Each hands requires atleast 15 to 30 seconds of handwashing to effectively removetransient microorganisms.


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55. The minimum time in washing each hand should never be below

A. 5 secondsB. 10 secondsC. 15 secondsD. 30 seconds

* According to Kozier, The minimum time required for watching each hands is 10 secondsand should not be lower than that. The recommended time, again, is 15 to 30 seconds.

56. How many ml of liquid soap is recommended for handwashing procedure?

A. 1-2 mlB. 2-3 mlC. 2-4 mlD. 5-10 ml

* If a liquid soap is to be used, 1 tsp [ 5ml ] of liquid soap is recommended for handwashing

procedure.

57. Which of the following is not true about sterilization, cleaning and disinfection?

A. Equipment w ith small lumen are easier to cleanB. Sterilization is the complete destruction of all viable microorganism including sporesC. Some organism are easily destroyed, while other, with coagulated protein requires longertimeD. The number of organism is directly proportional to the length of time required forsterilization* Equipments with LARGE LUMEN are easier to clean than those with small lumen. B C andD are all correct.

58. Karlita asked you, How long should she boil her glass baby bottle in water? Youcorrectly answered her by saying

A. The minimum time for boiling articles is 5 minutesB. Boil the glass baby bottler and other articles for atleast 10 minutesC. For boiling to be effective, a minimum of 15 minutes is required

D. It doesnt matter how long you boil the articles, as long as the water reached 100 degreeCelsius

* Boiling is the most common and least expensive method of sterilization used in home. Forit to be effective, you should boil articles for atleast 15 minutes.

59. This type of disinfection is best done in sterilizing drugs, foods and other things that arerequired to be sterilized before taken in by the human body

A. Boiling WaterB. Gas sterilizationC. Steam under pressureD. Radiation

* Imagine foods and drugs that are being sterilized by a boiling water, ethylene oxide gasand autoclave or steam under pressure, They will be inactivated by these methods.Ethylene oxide gas used in gas sterlization is TOXIC to humans. Boiling the food will alter its

consistency and nutrients. Autoclaving the food is never performed. Radiation using


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microwave oven or Ionizing radiation penetrates to foods and drugs thus, sterilizing them.

60. A TB patient was discharged in the hospital. A UV Lamp was placed in the room where

he stayed for a week. What type of disinfection is this?

A. Concurrent disinfectionB. Terminal disinfection

C. Regular disinfectionD. Routine disinfection

* Terminal disinfection refers to practices to remove pathogens that stayed in thebelongings or immediate environemnt of an infected client who has been discharged. An

example would be Killing airborne TB Bacilli using UV Light. Concurrent disinfection refers toongoing efforts implented during the client's stay to remove or limit pathogens in hissupplies, belongings, immediate environment in order to control the spread of the disease.An example is cleaning the bedside commode of a client with radium implant on her cervixwith a bleach disinfectant after each voiding.

61. Which of the following is not true in implementing medical asepsis

A. Wash hand before and after patient contactB. Keep soiled linens from touching the clothingsC. Shake the linens to remove dustD. Practice good hygiene

* NEVER shake the linens. Once soiled, fold it inwards clean surface out. Shaking the linenwill further spread pathogens that has been harbored by the fabric.

62. Which of the following is true about autoclaving or steam under pressure?

A. All kinds of microorganism and their spores are destroyed by autoclave machineB. The autoclaved instruments can be used for 1 month considering the bags are still intactC. The instruments are put into unlocked position, on their hinge, during theautoclaveD. Autoclaving different kinds of metals at one time is advisable

* Only C is correct. Metals with locks, like clamps and scissors should be UNLOCKED in

order to minimize stiffening caused by autoclave to the hinges of these metals. NOT ALLmicroorganism are destroyed by autoclaving. There are recently discovered microorganismthat is invulnarable to extreme heat. Autoclaved instruments are to be used within 2 weeks.Only the same type of metals should be autoclaved as this will alteration in plating of thesemetals.

63. Which of the following is true about masks?

A. Mask should only cover the noseB. Mask functions better if they are wet with alcoholC. Masks can provide durable protection even when worn for a long time and after each andevery patient careD. N95 Mask or particulate masks can filter organism as mall as 1 micromillimeter

* only D is correct. Mask should cover both nose and mouth. Masks will not functionoptimally when wet. Masks should be worn not greater than 4 hours, as it will loseeffectiveness after 4 hours. N95 mask or particulate mask can filter organism as small as 1

micromillimeter.

64. Where should you put a wet adult diaper?

A. Green trashcan


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B. Black trashcanC. Orange trashcanD. Yellow trashcan

* Infectious waste like blood and blood products, wet diapers and dressings are thrown inyellow trashcans.

65. Needles, scalpels, broken glass and lancets are considered as injurious wastes. As anurse, it is correct to put them at disposal via a/an

A. Puncture proof containerB. Reused PET Bottles

C. Black trashcanD. Yellow trashcan with a tag INJURIOUS WASTES

* Needles, scalpels and other sharps are to be disposed in a puncture proof container.

66. Miranda Priestly, An executive of RAMP magazine, was diagnosed with cancer of thecervix. You noticed that the radioactive internal implant protrudes to her vagina where

supposedly, it should be in her cervix. What should be your initial action?

A. Using a long forceps, Push it back towards the cervix then call the physicianB. Wear gloves, remove it gently and place it on a lead containerC. Using a long forceps, Remove it and place it on a lead container D. Call the physician, You are not allowed to touch, re insert or remove it

* A dislodged radioactive cervical implant in brachytherapy are to be picked by a LONGFORCEP and stored in a LEAD CONTAINER in order to prevent damage on the client's

normal tissue. Calling the physician is the second most appropriate action among thechoices. A nurse should never attempt to put it back nor, touch it with her bare hands.

67. After leech therapy, Where should you put the leeches?

A. In specially marked BIO HAZARD ContainersB. Yellow trashcanC. Black trashcanD. Leeches are brought back to the culture room, they are not thrown away for they are

reusable

* Leeches, in leech therapy or LEECH PHLEBOTOMY are to be disposed on a BIO HAZARDcontainer. They are never re used as this could cause transfer of infection. These leechesare hospital grown and not the usual leeches found in swamps.

68. Which of the following should the nurse AVOID doing in preventing spread of infection?

A. Recapping the needle before disposal to prevent injuriesB. Never pointing a needle towards a body partC. Using only Standard precaution to AIDS PatientsD. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie, with Neutropenia

* Never recap needles. They are directly disposed in a puncture proof container after used.Recapping the needles could cause injury to the nurse and spread of infection. B C and Dare all appropriate. Standard precaution is sufficient for an HIV patient. A client withneutropenia are not given fresh and uncooked fruits and vegetables for even the non

infective organisms found in these foods could cause severe infection on animmunocompromised patients.

69. Where should you put Mr. Alejar, with Category II TB?


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A. In a room with positive air pressure and atleast 3 air exchanges an hourB. In a room with positive air pressure and atleast 6 air exchanges an hourC. In a room with negative air pressure and atleast 3 air exchanges an hour

D. In a room w ith negative air pressure and atleast 6 air exchanges an hour

* TB patients should have a private room with negative air pressure and atleast 6 to 12 airexhanges per hour. Negative pressure room will prevent air inside the room from escaping.

Air exchanges are necessary since the client's room do not allow air to get out of the room.

70. A client has been diagnosed with RUBELLA. What precaution is used for this patient?

A. Standard precaution

B. Airborne precautionC. Droplet precautionD. Contact precaution

* Droplet precaution is sufficient on client's with RUBELLA or german measles.

71. A client has been diagnosed with MEASLES. What precaution is used for this patient?

A. Standard precautionB. Airborne precautionC. Droplet precautionD. Contact precaution

* Measles is highly communicable and more contagious than Rubella, It requires airborneprecaution as it is spread by small particle droplets that remains suspended in air anddisperesed by air movements.

72. A client has been diagnosed with IMPETIGO. What precaution is used for this patient?

A. Standard precautionB. Airborne precautionC. Droplet precautionD. Contact precaution

* Impetigo causes blisters or sores in the skin. It is generally caused by GABS or Staph

Aureaus. It is spread by skin to skin contact or by scratching the lesions and touchinganother person's skin.

73. The nurse is to insert an NG Tube when suddenly, she accidentally dip the end of thetube in the clients glass containing distilled drinking water which is definitely not sterile. Asa nurse, what should you do?

A. Dont mind the incident, continue to insert the NG TubeB. Obtain a new NG Tube for the clientC. Disinfect the NG Tube before reinserting it againD. Ask your senior nurse what to do

* The digestive tract is not sterile, and therefore, simple errors like this would not causeharm to the patient. NGT tube need not be sterile, and so is colostomy and rectal tubes.Clean technique is sufficient during NGT and colostomy care.

74. All of the following are principle of SURGICAL ASEPSIS except

A. Microorganism travels to moist surfaces faster than with dry surfaces

B. When in doubt about the sterility of an object, consider it not sterileC. Once the skin has been sterilized , considered it sterileD. If you can reach the object by overreaching, just move around the sterile field to pick it


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rather than reaching for it

* Human skin is impossible to be sterilized. It contains normal flora of microorganism. A B

and D are all correct.

75. Which of the following is true in SURGICAL ASEPSIS?

A. Autoclaved linens and gowns are considered sterile for about 4 months as long as thebagging is intactB. Surgical technique is a sole effort of each nurse

C. Sterile conscience, is the best method to enhance sterile techn iqueD. If a scrubbed person leaves the area of the sterile field, He/she must do handwashing

and gloving again, but the gown need not be changed.

* Sterile conscience, or the moral imperative of a nurse to be honest in practicing steriletechnique, is the best method to enhance sterile technique. Autoclaved linens areconsidered sterile only within 2 weeks even if the bagging is intact. Surgical technique is ateam effort of each nurse. If a scrubbed person leave the sterile field and area, he must dothe process all over again.

76. In putting sterile gloves, Which should be gloved first?

A. The dominant handB. The non dominant handC. The left handD. No specific order, Its up to the nurse for her own convenience

* Gloves are put on the non dominant hands first and then, the dominant hand. The

rationale is simply because humans tend to use the dominant hand first before the nondominant hand. Out of 10 humans that will put on their sterile gloves, 8 of them will put thegloves on their non dominant hands first.

77. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior tothe operation?

A. Immediately after entering the sterile field

B. After surgical hand scrubC. Before surg ical hand scrubD. Before entering the sterile field

* The nurse should put his goggles, cap and mask prior to washing the hands. If he washhis hands prior to putting all these equipments, he must wash his hands again as theseequipments are said to be UNSTERILE.

78. Which of the following should the nurse do when applying gloves prior to a surgicalprocedure?

A. Slipping gloved hand with all fingers when picking up the second gloveB. Grasping the first glove by inserting four fingers, with thumbs up underneath the cuffC. Putting the gloves into the dominant hand firstD. Adjust only the fitting o f the gloves after both g loves are on

* The nurse should only adjust fitting of the gloves when they are both on the hands. Notdoing so will break the sterile technique. Only 4 gingers are slipped when picking up the

second gloves. You cannot slip all of your fingers as the cuff is limited and the thumb wouldnot be able to enter the cuff. The first glove is grasp by simply picking it up with the first 2

fingers and a thumb in a pinching motion. Gloves are put on the non dominant hands first.

79. Which gloves should you remove first?


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A. The glove of the non dominant handB. The glove of the dominant hand

C. The glove of the left handD. Order in removing the gloves Is unnecessary

* Gloves are worn in the non dominant hand first, and is removed also from the non

dominant hand first. Rationale is simply because in 10 people removing gloves, 8 of themwill use the dominant hand first and remove the gloves of the non dominant hand.

80. Before a surgical procedure, Give the sequence on applying the protective items listedbelow

1. Eye wear or goggles2. Cap3. Mask4. Gloves5. Gown

A. 3,2,1,5,4B. 3,2,1,4,5C. 2,3,1,5,4D. 2,3,1,4,5

* The nurse should use CaMEy Hand and Body Lotion in moisturizing his hand beforesurgical procedure and after handwashing. Ca stands for CAP, M stands for MASK, Eystands for eye goggles. The nurse will do handwashing and then [HAND], Don the glovesfirst and wear the Gown [BODY]. I created this mnemonic and I advise you use it because

you can never forget Camey hand and body lotion. [ Yes, I know it is spelled as CAMAY ]]

81. In removing protective devices, which should be the exact sequence?

1. Eye wear or goggles2. Cap3. Mask4. Gloves5. Gown

A. 4,3,5,1,2B. 2,3,1,5,4C. 5,4,3,2,1D. 1,2,3,4,5

* When the nurse is about to remove his protective devices, The nurse will remove the

GLOVES first followed by the MASK and GOWN then, other devices like cap, shoe cover, etc.This is to prevent contamination of hair, neck and face area.

82. In pouring a plain NSS into a receptacle located in a sterile field, how high should thenurse hold the bottle above the receptacle?

A. 1 inchB. 3 inchesC. 6 inchesD. 10 inches

* Even if you do not know the answer to this question, you can answer it correctly by

imagining. If you pour the NSS into a receptacle 1 to 3 inch above it, Chances are, Themouth of the NSS bottle would dip into the receptacle as you fill it, making it contaminated.If you pour the NSS bottle into a receptacle 10 inches above it, that is too high, chances


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are, as you pour the NSS, most will spill out because the force will be too much for thebuoyant force to handle. It will also be difficult to pour something precisely into a receptacleas the height increases between the receptacle and the bottle. 6 inches is the correct

answer. It is not to low nor too high.

83. The tip of the sterile forceps is considered sterile. It is used to manipulate the objects inthe sterile field using the non sterile hands. How should the nurse hold a sterile forceps?

A. The tip should always be lower than the handleB. The tip should always be above the handle

C. The handle and the tip should be at the same levelD. The handle should point downward and the tip, always upward

* A sterile forcep is usually dipped into a disinfectant or germicidal solution. Imagine, if thetip is HIGHER than the handle, the solution will go into the handle and into your hands andas you use the forcep, you will eventually lower its tip making the solution in your hand goBACK into the tip thus contaminating the sterile area of the forcep. To prevent this, the tipshould always be lower than the handle. In situation questions like this, IMAGINATION isvery important.

84. The nurse enters the room of the client on airborne precaution due to tuberculosis.Which of the following are appropriate actions by the nurse?

1. She wears mask, covering the nose and mouth2. She washes her hands before and after removing gloves, after suctioning the clientssecretion3. She removes gloves and hands before leaving the clients room4. She discards contaminated suction catheter tip in trashcan found in the clients room

A. 1,2B. 1,2,3C. 1,2,3,4D. 1,3

* All soiled equipments use in an infectious client are disposed INSIDE the client's room toprevent contamination outside the client's room. The nurse is correct in using Mask thecovers both nose and mouth. Hands are washed before and after removing the gloves and

before and after you enter the client's room. Gloves and contaminated suction tip arethrown in trashcan found in the clients room.

85. When performing surgical hand scrub, which of the following nursing action is requiredto prevent contamination?

1. Keep fingernail short, clean and with nail polish

2. Open faucet with knee or foot control3. Keep hands above the elbow when washing and rinsing4. Wear cap, mask, shoe cover after you scrubbed

A. 1,2B. 2,3C. 1,2,3D. 2,3,4

* Cap, mask and shoe cover are worn BEFORE scrubbing.

86. When removing gloves, which of the following is an inappropriate nursing action?

A. Wash gloved hand firstB. Peel off gloves inside out


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C. Use glove to glove skin to skin techniqueD. Remove mask and gow n before removing gloves

* Gloves are the dirtiest protective item nurses are wearing and therefore, the first to beremoved to prevent spread of microorganism as you remove the mask and gown.

87. Which of the following is TRUE in the concept of stress?

A. Stress is not always present in diseases and illnessesB. Stress are only psychological and manifests psychological symptoms

C. All stressors evoke common adaptive responseD. Hemostasis refers to the dynamic state of equilibrium

* All stressors evoke common adaptive response. A psychologic fear like nightmare and areal fear or real perceive threat evokes common manifestation like tachycardia, tachypnea,sweating, increase muscle tension etc. ALL diseases and illness causes stress. Stress can beboth REAL or IMAGINARY. Hemostasis refers to the ARREST of blood flowing abnormallythrough a damage vessel. Homeostasis is the one that refers to dynamic state ofequilibrium according to Walter Cannon.

88. According to this theorist, in his modern stress theory, Stress is the non specificresponse of the body to any demand made upon it.

A. Hans SelyeB. Walter CannonC. Claude BernardD. Martha Rogers

* Hans Selye is the only theorist who proposed an intriguing theory about stress that hasbeen widely used and accepted by professionals today. He conceptualized two types ofhuman response to stress, The GAS or general adaptation syndrome which is characterizedby stages of ALARM, RESISTANCE and EXHAUSTION. The Local adaptation syndromecontrols stress through a particular body part. Example is when you have been wounded inyour finger, it will produce PAIN to let you know that you should protect that particulardamaged area, it will also produce inflammation to limit and control the spread of injury andfacilitate healing process. Another example is when you are frequently lifting heavy objects,

eventually, you arm, back and leg muscles hypertorphies to adapt to the stress of heavylifting.

89. Which of the following is NOT TRUE with regards to the concept of Modern StressTheory?

A. Stress is not a nervous energyB. Man, whenever he encounters stresses, always adapts to it

C. Stress is not always something to be avoidedD. Stress does not always lead to distress

* Man, do not always adapt to stress. Sometimes, stress can lead to exhaustion andeventually, death. A,C and D are all correct.

90. Which of the following is TRUE with regards to the concept of Modern Stress Theory?

A. Stress is essentialB. Man does not encounter stress if he is asleep

C. A single stress can cause a diseaseD. Stress always leads to distress

* Stress is ESSENTIAL. No man can live normally without stress. It is essential because it isevoked by the body's normal pattern of response and leads to a favorable adaptive


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mechanism that are utilized in the future when more stressors are encountered by thebody. Man can encounter stress even while asleep, example is nightmare. Disease aremultifactorial, No diseases are caused by a single stressors. Stress are sometimes favorable

and are not always a cause for distress. An example of favorable stress is when a carpentermeets the demand and stress of everyday work. He then develops calluses on the hand tolessen the pressure of the hammer against the tissues of his hand. He also develop largermuscle and more dense bones in the arm, thus, a stress will lead to adaptations to decrease

that particular stress.

91. Which of the following is TRUE in the stage of alarm of general adaptation syndrome?

A. Results from the prolonged exposure to stress

B. Levels or resistance is increasedC. Characterized by adaptationD. Death can ensue

* Death can ensue as early as the stage of alarm. Exhaustion results to a prolongedexposure to stress. Resistance is when the levels of resistance increases and characterizedby being able to adapt.

92. The stage of GAS where the adaptation mechanism begins

A. Stage of A larmB. Stage of ResistanceC. Stage of HomeostasisD. Stage of Exhaustion

* Adaptation mechanisms begin in the stage of alarm. This is when the adaptive mechanism

are mobilized. When someone shouts SUNOG!!! your heart will begin to beat faster, youvessels constricted and bp increased.

93. Stage of GAS Characterized by adaptation

A. Stage of AlarmB. Stage of ResistanceC. Stage of HomeostasisD. Stage of Exhaustion

94. Stage of GAS wherein, the Level of resistance are decreased

A. Stage of A larmB. Stage of ResistanceC. Stage of HomeostasisD. Stage of Exhaustion

* Resistance are decreased in the stage of alarm. Resistance is absent in the stage ofexhaustion. Resistance is increased in the stage of resistance.

95. Where in stages of GAS does a person moves back into HOMEOSTASIS?

A. Stage of AlarmB. Stage of ResistanceC. Stage of HomeostasisD. Stage of Exhaustion

96. Stage of GAS that results from prolonged exposure to stress. Here, death will ensue

unless extra adaptive mechanisms are utilized

A. Stage of Alarm


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B. Stage of ResistanceC. Stage of HomeostasisD. Stage of Exhaustion

97. All but one is a characteristic of adaptive response

A. This is an attempt to maintain homeostasis

B. There is a totality of responseC. Adaptive response is immediately mob ilized, doesnt require timeD. Response varies from person to person

* Aside from having limits that leads to exhaustion. Adaptive response requires time for it

to act. It requires energy, physical and psychological taxes that needs time for our body tomobilize and utilize.

98. Andy, a newly hired nurse, starts to learn the new technology and electronic devices atthe hospital. Which of the following mode of adaptation is Andy experiencing?

A. Biologic/Physiologic adaptive mode

B. Psychologic adaptive modeC. Sociocultural adaptive modeD. Technological adaptive mode

99. Andy is not yet fluent in French, but he works in Quebec where majority speaks French.He is starting to learn the language of the people. What type of adaptation is Andyexperiencing?

A. Biologic/Physiologic adaptive mode

B. Psychologic adaptive modeC. Sociocultural adaptive modeD. Technological adaptive mode

* Sociocultural adaptive modes include language, communication, dressing, acting andsocializing in line with the social and cultural standard of the people around the adaptingindividual.

100. Andy made an error and his senior nurse issued a written warning. Andy arrived in his

house mad and kicked the door hard to shut it off. What adaptation mode is this?

A. Biologic/Physiologic adaptive modeB. Psycho logic adaptive modeC. Sociocultural adaptive modeD. Technological adaptive mode

* Andy uses a defense mechanism called DISPLACEMENT. All DMs are categorized asPSYCHOLOGIC ADAPTIVE RESPONSE to stressors.

Fundamentals of Nursing (2) - 100 Items - Answers and Rationale

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