COMPREHENSIVE NURSING REVIEW by R. C. REÑA 225 PAGES

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COMPREHENSIVE NURSING REVIEW by R. C. REÑA 225 PAGES Fundamentals of Nursing Maternity Nursing Pediatric Nursing Community Health Nursing Medical Surgical Nursing Psychiatric Nursing Professional ... Adjustment Leadership and Management Nursing Research Compiled by: ROBERT C. REÑA 2009 THE EVER POPULAR LAST MINUTE TIPS FORCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 2 NURSING LICENSURE EXAMINATIONS In NP1, Please FOCUS on the following: 1. Types of leadership: Autocratic, Laissez faire, Democratic, transformational, transactional etc. etc. 2. Pattern of Nursing care: Primary nursing, case nursing, functional, team etc. 3. Expanded Nursing role: Nurse anesthetist, Nurse practitioner, Nurse researcher etc. etc. 4. Levels of prevention by Leavell and Clark. Remember that crisis is always secondary. 5. 3 way bottle system: simply reconnect the tube, continuous bubble is a sign of leakage, no bubbling is obstruction [in the waterseal] and you should palpate the surrounding area for subcutaneous emphysema 6. Care of clients with tracheostomy and suctioning a tracheostomy tube [sterile technique] know the functions of the cuff, obturator and the tie. care of clients with pooling of secretions. Postural drainage: do this before meals, the positioning depending on the location of secretion, POPEVICO [arrangement] that is positioning, percussing, vibrating and coughing etc. study suctioning. 7. The independent and the dependent variable in research 8. Know your PURE and APPLIED as well as EXPERIMENTAL and NON-EXPERIMENTAL also your QUANTITATIVE and QUALITATIVE designs 9. IV fluid tonicity: D5LR is hypertonic while LR is isotonic 10. Complication of IV and its intervention such as FLUID OVERLOAD, PHLEBITIS, INFILTRATION. 11. Blood transfusion 12. Complication of immobility: DECUBITUS ULCER, HYPO PNEUMONIA, ATELECTASIS, DEEP VEIN THROMBOSIS 13. The VIRTUE ETHICS and ETHICS: Justice, fortitude, prudence, temperance, character, double effect, paternalism... etc etc and the Patient's bill of right. 15. Teaching and learning steps: Man initially needs information and MOTIVATION is needed for adherence to teaching. First step in teaching is to ASSESS LEARNING NEEDS before planning what to teach. 16. SAFETY: Causes of injuries according to age eg: elderly = falls, infant = suffocation and aspiration, adolescence = suicide and homicide. Intervention in an elderly client who falls frequently = keep the bed at the lowest possible position. etc. 18. BON RESOLUTION 220 [CODE OF ETHICS] RA 9173 AND 7164 [COMPARE AND CONTRAST] and the CONTINUING PROFESSIONAL EDUCATION. [To enhance knowledge with regard to specific field of interest] NP2 1. Stages of labor. The first stage up to the fourth stage and the LATENT ACTIVE AND TRANSITION of the first stage. study the intervention in all stages. Read pilleteri for this. 2. The menstrual cycle, what glands secret what hormones. The MENSTRUAL, PROLIFERATIVE, SECRETORY and ISCHEMIC phase. what hormone is at peak during what stage. etc. etc. 3. Causes of bleeding during pregnancy: Ectopic, abruptio and previa plus their nursing intervention. 4. Endometriosis and Endometritis. 5. IMCI : Pneumonia, Diarrhea and Dengue especially the breathing cut off [Eg. 60 for under 2 months], Acute/Chronic cutoff [Acute diarrhea and ear infection under 14 days]. The interventions for CHILD A, B and C.COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 3 6. COMMUNITY HEALTH NURSING PROCESS: Assessment, Planning, Implementation and Evaluation. refer to the DOH book please read this one. 7. Managerial principles. PODC. Types of budgets. Direct, indirect, cash, capital, operational budgets. 8. Read pilleteri for : Characteristic of a toddler and preschool [ eg : asking too many questions, negativistic for toddler. Preschool = associative, imaginary, see the world on his own point of view, superego development etc.] 9. POISONING: Lead, aspirin, etc. etc. this is the common cause of accident among toddlers. 10. Leukemia, Anemia and Sickle cell anemia, chemotherapy for pediatric clients. 11. NEWBORN SCREENING 12. Amniocentesis = VOID, Ultrasonography = DRINK, Leopolds Maneuver = VOID, Paracentesis = VOID 13. Changes during pregnancy [eg: Leukorrhea, braxton hicks, anemia] and what changes occurs early or late. Refer to Pillitteri 14. Pregnancy and nutrition: Balanced diet + 300 cal for pregnant. +500 cal for breastfeeding 15. PIH and MAGNESIUM SULFATE. [cns down, rr down, u/o down ] priority : RR NP3 AND NP4 1. Burns, Classification of Burns and Nursing Diagnosis for Burns, Drug use in burns [Silver Sulfadiazine], Electrolyte changes in burn [Hyperkalemia, Hyponatermia]. The WHO Pain ladder scale, Pain medications especially Demerol, Morphine and Fentanyl. Remember that PAIN is the hardest part for the nurse in caring for a burned victim. Burn wounds heal by secondary intention. 2. Nursing diagnosis after anesthesia : RISK FOR INFECTION or INEFFECTIVE AIR CLEARANCE. 3. PACU MONITORING = Q15 , SURGICAL FLOOR MONITORING = Q30 4. Pancreatitis, Cholecystitis, Hepatitis. Morphine causes spasms in the sphincter of oddi. Hepa B is caused by blood exchange. Hepa A is oro-fecal. both have vaccines either passive or active but if already exposed, Give PASSIVE. 5. Diabetes mellitus, Metformin and contrast medium [stop metformin due to renal toxicity], Insulin rotation and administration, diabetes r/t footcare. Avoid wearing canvass shoes, check for the sensation, do not go outside without slippers. PERIPHERAL NEUROPATHY. OHA drugs. 6. Electrolytes abnormality especially HYPOCALCEMIA and HYPER/HYPOKALEMIA. The ECG changes in potassium alteration, intervention and causes. 7. Myocardial infarction : ECG changes as well as nursing intervention. Causes and risk factors. Refer to BRUNNER. 8. Pharmacologic and Nonpharmacologic pain relief : Guided imagery, Biofeedback, Intrathecal [into the spinal canal directly to mix with csf] and epidural [ into the epidural space ] pain management. side effects of morphine in elderly = PRURITUS and ALLERGIC RXN and RR DEPRESSION. Reason for intrathecal admininstration = prevent Blood brain barrier. 9. BREAST and CERVICAL cancer. Assessment, Diagnosis and Treatment. 10. Management for a client with COLOSTOMY. The irrigation, diet and body image alteration as well as perioperative management of a client undergoing your ABDOMINAL PERINEAL RESECTION with permanent colostomy. Drugs given before APR such as neomycin and sulfasuzidine, Diet before APR [low fiber], normal color of the stoma just after APR [slightly bleeding, red and protruding] 11. Insulin administration, types and rotation. Refer to brunner. 1 inch away from each injection site, administer at room temp not cold to prevent lipodystrophy, abdomen has the fastest absorption. etc. etc. 12. Interventions during hypo- and hyperglycemiaCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 4 13. Care of clients with hyper- and hypothyroidism, study TAPAZOLE/METHIMAZOLE and LUGOL'S SOLUTION, PTU. Care of clients after thyroidectomy: Monitor for hypocalcemia teach clients HEAD SUPPORT by putting hands at the back of the neck before trying to move the head. 14. Tuberculosis and Leprosy, its early / late sign and symptoms. 15. Acute and Chronic renal failure. Causes [Post/pre/intra] and hemodialysis. 16. AGN, Rheumathoid and Ostearthritis, Bell's Palsy and Trigeminal neuralgia 17. Study radiation and chemotherapy and their usual side effects [Skin burn, redness, do not wet radiation mark]. Mammography, BSE, TSE, DRE, Prostate and Colon cancer, Changes that occurs during elderly, Bladder, Colon and Cervical cancer Diagnostic examination/CEA, Proctosigmoidoscopy, Biopsy, Pap smear. 18. Laryngeal cancer and tracheostomy care. [refer to Kozier for tracheostomy care] NP5 1. In your Test V study the following: Anxiety and anxiety disorders, The level of anxiety and your anxiolytics, Schizophrenia: Paranoid type and Catatonic type and your nursing interventions for these clients as well as your priority nursing diagnosis. 2. Depression and your antidepressants, Mania, Personality disorders especially your Antisocial, Borderline and Paranoid. The defense mechanism use for different types of disorders and the priority NURSING DIAGNOSIS for each psychiatric disorders, Antipsychotic drugs its side effects and nursing intervention for each side effects. 3. Electroconvulsive therapy, Thought process disturbance manifestation such as Clang Association, Pressured speech, Thought blocking, Word salad, perseveration etc. etc. Alteration in perception and thought like hallucination and delusion. Types of delusions eg. religious and persecutory. Activities and diet as well as nursing diagnosis for a client with Mania, Depressed and Alzheimer’s/Dementia patient. 4. Eating disorders and the treatments of choice [Behavior therapy for Anorexia, Psychotherapy for the Personality Disorders, Cognitive therapy for depression ] Always answer "STAY WITH THE CLIENT" especially if the question is about anxiety disorders and panic attacks. Always choose an option that will encourage verbalization of feelings, never answer an option with the word WHY. 5. Study your counter transference and your transference, Glaucoma, Cataract and crutch/cane walking. The principles of body mechanics, cranial nerve functioning and how to assess them as well as their disturbances especially Bells and Trigeminal Neuralgia. Meniere's disease, Delirum, Dementia, CVA/Stroke pathophysiology and Factors. 6. Psychotherapy : Behavior therapy - aversion, operant conditioning [positive reinforcement] systematic desensitization. Cognitive therapy is the PSYCHOTHERAPY of choice for depression. Study therapeutic milieu - general pt management, environmental manipulation, uses democratic leadership to test new patterns of behavior. Community meeting is the heart of milieu therapy. Pharmacotherapy: Drug classification and side effects of ANTIPSYCHOTIC, ANXIOLYTICS, ANTIMANIC [Tegretrol, Lithium, Depakene] 7. Transfer of clients from BED to CHAIR as well as MOVING CLIENT UP IN BED [READ KOZIER] 8. Supporting the client in: SUPINE [eg. prevent neck hyperextension by putting pillow], FOWLERS [prevent posterior curvature of the spine], DORSAL RECUMBENT [prevent hyperextension of the knee] AND SIDELYING position [Prevent lateral flexion of the sternocleidomastoid] 9. Equipments for immobility : Trochanter roll/sandbags - prevent external rotation of the hips. Pillow to support back, head, arms and shoulders. Footboard to prevent footdrop. Trapeze bar to move the client up in bed. Knee gatch or pillow - to slightly flex the clients knee. 10. INTRODUCE CHANGE GRADUALLY - Study methods of implementing change such as FORCE FIELD ANALYSIS - THE DRIVING AND THE RESTRAINING FORCES, FOCUS - FIND ORGANIZE CLARIFY UNDERSTAND SOLUTION. THE PDSA CYCLE - PLAN DO STUDY ACT.COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 5 THE 6 TECHNICAL TIPS FOR THE BOARD EXAMINATION 1. Accept the fact that you can never know everything. Therefore, once you see an unfamiliar question that was never been taught, use your test taking strategies. 2. If you are in Test I, II, III, and IV and you are being asked to prioritize, Use ABC first and then Maslow's Hierarchy of needs. 3. The use of your nursing process is heralded by the word: "The Nurse Would or The nurse's initial action" Remember to Assess first before intervening. If the situation and the question already assessed the patient, then proceed with the next step. 4. Encircle your modifiers. Some people make mistakes because of failure to see the word, "EXCEPT" or "NOT" or "INAPPROPRIATE", etc. The magic words… 5. Use your questionnaires as your scratch. You can write anything on that paper. If you will skip a number, place an asterisk or encircle the number. 6. DO NOT USE BLUNT PENCIL. Always use a sharp one and shade lightly. A sharpened pencil will give a very dark shade even if you will shade it lightly. Use the sides of the pencil not the tip. Use MONGOL NUMBER 2 ONLY. Some brands especially those made in china pencils are substandard. The machine will check the lead. If you are INCONSISTENT with your shading like an altering dark and light shades, you will FAIL the boards because of technicalities. References: Adele Pillitteri. MATERNAL & CHILD HEALTH NURSING: Care of the Childbearing & Childrearing Family. 2005 www.nursingcrib.com www.scribd.com Care has been taken to confirm the accuracy of the information presented. Nevertheless, it is difficult to ensure that all the information presented is entirely accurate for all circumstances, and the author cannot accept any responsibility for any error or omission. The author makes no warranty, expressed or implied, with respect to this work, and disclaims any liability, loss, or damage as a consequence, directly or indirectly, of the use and application of any of the contents of this workCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 6 PRAYERS TO ST. JOSEPH OF CUPERTINO FOR SUCCESS IN EXAMINATIONS First Prayer O Great St. Joseph of Cupertino who while on earth did obtain from God the grace to be asked at your examination only the questions you knew, obtain for me a like favour in the examinations for which I am now preparing. In return I promise to make you known and cause you to be invoked. Through Christ our Lord. St. Joseph of Cupertino, Pray for us. Amen. Second Prayer O St. Joseph of Cupertino who by your prayer obtained from God to be asked at your examination, the only preposition you knew. Grant that I may like you succeed in the Nursing Licensure Examination. In return, I promise to make you known and cause you to be invoked. O St. Joseph of Cupertino pray for me O Holy Ghost enlighten me Our Lady of Good Studies pray for me Sacred Head of Jesus, Seat of divine wisdom, enlighten me. PRAYER TO SAINT JUDE THADDEUS, PATRON OF THE IMPOSSIBLE Most Holy Apostle St. Jude, faithful servant and friend of Jesus, the church honors and invokes you universally as the patron of difficult cases, of things almost despaired of, pray for me. I am so helpless and alone. Intercede to God for me that He brings visible and speedy help where help is almost despaired of. Come to my assistance in this great need that I may receive the consolation and help of heaven in all my necessities, tribulations and sufferings particularly (here make your request) and that I may praise God with you and all the saints forever. I promise, O Blessed St. Jude, to be ever mindful of this great favor granted to me by God and to always honor you as my special and powerful patron and to gratefully encourage devotion to you. Amen.COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 7 PRINCIPLES OF TEST TAKING I. PRINCIPLE OF CONTRADICTION When two options contradict each other, there is a higher chance of one of them being the correct answer. Example: Which physiologic effect should the nurse expect in a client addicted to hallucinogens? A. Dilated pupils B. Constricted pupils C. Bradycardia D. Bradypnea II. PRINCIPLE OF COMMONALITY AND DIFFERENCE Two or more options that has the same essential configuration and thought is unlikely the correct answer. Example: When injecting subcutaneous injection in an obese patient, it should be angled at around: A. 45° B. 90° C. 180° D. Parallel to the skin III. PRINCIPLE OF CENTRAL TENDENCY Correct answers in an all numeric options is most likely located in between the extremes. Example: What is the KVO rate of BT? A. 5 gtts/min B. 10 gtts/min C. 15 gtts/min D. 20 gtts/min IV. PRINCIPLE OF POSITIVE AND NEGATIVE HARMONY A positive question will always ask for a positive answer and so is a negative question. FORMULA: [-] [-] = + Question [+] [+] = + Question [-] [+] = - Question Example: All but one of the following is an Anxiolytic: [+] [-] A. Tranxene B. Miltown C. Atarax D. Parlodel V. PRINCIPLE OF IMPROBABLE EXTREMES Extreme modifiers, such as always, all, never, or only make it more likely that the question is false. Here is a more complete list of EXTREME modifiers. All, every, nothing, none, best, absolutely, always, never, worst, absolutely not, only, nobody, everybody, certainly, invariably, no one, everyone, certainly not. Example: The most effective way in limiting the number of microorganism in the hospital is: A. Using strict aseptic technique in all procedures B. Wearing mask and gown in care of all patients with communicable diseases C. Sterilization of all instruments D. Handwashing VI. PRINCIPLE OF INITIATIVE CRITICAL THINKING 1. Cover the options 2. Read the question carefully 3. Try answering the question without looking at the options 4. Select the option that most closely matches your answer Example: The nurse knew that the normal color of Michiel’s stoma should be: A. Brick Red B. Gray C. Blue D. Pale PinkCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8 VII. PRINCIPLE OF GRAMMATICAL HARMONY Options that do not coincide with the grammatical configuration of the stem is NOT the correct answer. Choices that are grammatically incorrect or contain typographical errors are probably not the correct answer. Example: When planning a care for a client who is pancytopenic, The major goal should be: C.Prevent hemorrhage, infection and decrease oxygenation B. Administering an oral iron preparation C. Preventing Fatigue and fluid overload D. Encouraging a consumption of a neutropenic diet VIII. PRINCIPLE OF UMBRELLA EFFECT A choice that is more inclusive is usually the correct answer. Example: To view a person holistically, the nurse should think of him or her as: A. Physical being who experiences pathology and sociological changes B. Social being who needs the dynamics of group interaction C. Psychological being whose mind influences his or her health status D. Biopsychosocial being who is in constant interaction with the environment IX. Principle of ABC, Maslow’s Hierarchy and Nursing Process When questions require prioritization, these principles should apply. Keywords that indicate the need to prioritize include: BEST VITAL ESSENTIAL FIRST IMMEDIATE PRIMARY HIGHEST PRIORITY INITIAL MOST IMPORTANT NEXT Example: A nurse is reviewing the plan of care for a pregant client with a diagnosis of sickle cell anemia. Which nursing diagnosis, if stated on the plan of care, would the nurse select as receiving the highest priority? A.Anxiety B.Ineffective coping C.Disturbed body image D.Deficient fluid volume Example: When caring for Aida after a chest surgery, your priority would be to maintain: A. Supplementary oxygen B. Chest tube drainage C. Blood replacement D. Ventilation exchange X. Principle of “Tell Me More” In Psychiatric Nursing, Remember to focus on the client’s feeling, concerns, anxieties and fears. This is best summarized by a response that encourages the client’s verbalization of feelings. Example: A mother says to the nurse, “I am afraid that my child might have another seizure” Which response by the nurse is most therapeutic? A. “Why worry about something you cannot control?” B. “Most children will never experience a second seizure” C. “Tell me what frightens you the most about seizures.” D. “Tylenol can prevent another seizure from occuring” XI. Principle of Reappearing Visage A word or phrase that appears in the question and then reappears at one of the 4 choices is the most probable answer. Example: A chronically ill school-age child is most vulnerable to which stressor? A. Mutilation anxiety B. Anticipatory grief C. Anxiety over school absences D. Fear of hospital proceduresCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 9 XII. The Drug Technique Most drugs, especially psychotropic medications either act as a CNS Stimulant or a CNS depressant. The strategy revolves in determining which are the Central nervous system excitations and which are the Central nervous system inhibitions. If 3 of the options are all CNS up and 1 is CNS down, pick the CNS down. If 3 of the options are all CNS down and 1 is CNS up, pick the CNS up. Example: The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent? A. Combativeness, sweating, and confusion B. Agitation, hyperactivity, and grandiose ideation C. Suspiciousness, dilated pupils, and increased blood pressure D. Emotionally blunt, lethargy and impaired memoryCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 10 CONTENTS FUNDAMENTALS OF NURSING ............…...………12 MATERNITY NURSING …………………….……… 33 PEDIATRIC NURSING………………………..………57 COMMUNITY HEALTH NURSING …………………67 MEDICAL SURGICAL NURSING ………………..… 95 PSYCHIATRIC NURSING ……………………........... 117 PROFESSIONAL ADJUSTMENT …..………………. 141 LEADERSHIP and MANAGEMENT ……………….. 144 NURSING RESEARCH ……………………..………...156 COMPREHENSIVE EXAMINATION ……………….. 173COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 11COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 12 FUNDAMENTALS OF NURSING PART 1 1. Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? a. Providing a back massage b. Feeding a client c. Providing hair care d. Providing oral hygiene 2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature? a. Oral b. Axillary c. Radial d. Heat sensitive tape 3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document this findings as: a. Tachypnea b. Hyper pyrexia c. Arrythmia d. Tachycardia 4. Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair? a. Bend at the waist and place arms under the client’s arms and lift b. Face the client, bend knees and place hands on client’s forearm and lift c. Spread his or her feet apart d. Tighten his or her pelvic muscles 5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature? a. Oral b. Axillary c. Arterial line d. Rectal 6. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is: a. Fowler’s position b. Side lying c. Supine d. Trendelenburg 7. A client is hospitalized for the first time, which of the following actions ensure the safety of the client? a. Keep unnecessary furniture out of the way b. Keep the lights on at all time c. Keep side rails up at all time d. Keep all equipment out of view 8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? a. Assessment b. Diagnosis c. Planning d. Implementation 9. It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community a. Assessment b. Nursing Process c. Diagnosis d. Implementation 10. Exchange of gases takes place in which of the following organ? a. Kidney b. Lungs c. Liver d. Heart 11. The Chamber of the heart that receives oxygenated blood from the lungs is the? a. Left atriumCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 13 b. Right atrium c. Left ventricle d. Right ventricle 12. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of food… a. Gallbladder b. Urinary bladder c. Stomach d. Lungs 13. The ability of the body to defend itself against scientific invading agent such as baceria, toxin, viruses and foreign body a. Hormones b. Secretion c. Immunity d. Glands 14. Hormones secreted by Islets of Langerhans a. Progesterone b. Testosterone c. Insulin d. Hemoglobin 15. It is a transparent membrane that focuses the light that enters the eyes to the retina. a. Lens b. Sclera c. Cornea d. Pupils 16. Which of the following is included in Orem’s theory? a. Maintenance of a sufficient intake of air b. Self perception c. Love and belonging d. Physiologic needs 17. Which of the following cluster of data belong to Maslow’s hierarchy of needs a. Love and belonging b. Physiologic needs c. Self actualization d. All of the above 18. This is characterized by severe symptoms relatively of short duration. a. Chronic Illness b. Acute Illness c. Pain d. Syndrome 19. Which of the following is the nurse’s role in the health promotion a. Health risk appraisal b. Teach client to be effective health consumer c. Worksite wellness d. None of the above 20. It is describe as a collection of people who share some attributes of their lives. a. Family b. Illness c. Community d. Nursing 21. Five teaspoon is equivalent to how many milliliters (ml)? a. 30 ml b. 25 ml c. 12 ml d. 75 ml 22. 1800 ml is equal to how many liters? a. 1.8 b. 18000 c. 180 d. 2800 23. Which of the following is the abbreviation of drops? a. Gtt. b. Gtts. c. Dp. d. Dr.COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 14 24. The abbreviation for micro drop is… a. µgtt b. gtt c. mdr d. mgts 25. Which of the following is the meaning of PRN? a. When advice b. Immediately c. When necessary d. Now 26. Which of the following is the appropriate meaning of CBR? a. Cardiac Board Room b. Complete Bathroom c. Complete Bed Rest d. Complete Board Room 27. 1 tsp is equals to how many drops? a. 15 b. 60 c. 10 d. 30 28. 20 cc is equal to how many ml? a. 2 b. 20 c. 2000 d. 20000 29. 1 cup is equal to how many ounces? a. 8 b. 80 c. 800 d. 8000 30. The nurse must verify the client’s identity before administration of medication. Which of the following is the safest way to identify the client? a. Ask the client his name b. Check the client’s identification band c. State the client’s name aloud and have the client repeat it d. Check the room number 31. The nurse prepares to administer buccal medication. The medicine should be placed… a. On the client’s skin b. Between the client’s cheeks and gums c. Under the client’s tongue d. On the client’s conjuctiva 32. The nurse administers cleansing enema. The common position for this procedure is… a. Sims left lateral b. Dorsal Recumbent c. Supine d. Prone 33. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which of the following measures the nurse should do? a. Dissolve the capsule in a glass of water b. Break the capsule and give the content with an applesauce c. Check the availability of a liquid preparation d. Crash the capsule and place it under the tongue 34. Which of the following is the appropriate route of administration for insulin? a. Intramuscular b. Intradermal c. Subcutaneous d. Intravenous 35. The nurse is ordered to administer ampicillin capsule TIP p.o. The nurse shoud give the medication… a. Three times a day orally b. Three times a day after meals c. Two time a day by mouth d. Two times a day before meals 36. Back Care is best describe as: a. Caring for the back by means of massage b. Washing of the backCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 15 c. Application of cold compress at the back d. Application of hot compress at the back 37. It refers to the preparation of the bed with a new set of linens a. Bed bath b. Bed making c. Bed shampoo d. Bed lining 38. Which of the following is the most important purpose of handwashing a. To promote hand circulation b. To prevent the transfer of microorganism c. To avoid touching the client with a dirty hand d. To provide comfort 39. What should be done in order to prevent contaminating of the environment in bed making? a. Avoid funning soiled linens b. Strip all linens at the same time c. Finished both sides at the time d. Embrace soiled linen 40. The most important purpose of cleansing bed bath is: a. To cleanse, refresh and give comfort to the client who must remain in bed b. To expose the necessary parts of the body c. To develop skills in bed bath d. To check the body temperature of the client in bed 41. Which of the following technique involves the sense of sight? a. Inspection b. Palpation c. Percussion d. Auscultation 42. The first techniques used examining the abdomen of a client is: a. Palpation b. Auscultation c. Percussion d. Inspection 43. A technique in physical examination that is use to assess the movement of air through the tracheobronchial tree: a. Palpation b. Auscultation c. Inspection d. Percussion 44. An instrument used for auscultation is: a. Percussion-hammer b. Audiometer c. Stethoscope d. Sphygmomanometer 45. Resonance is best describe as: a. Sounds created by air filled lungs b. Short, high pitch and thudding c. Moderately loud with musical quality d. Drum-like 46. The best position for examining the rectum is: a. Prone b. Sim’s c. Knee-chest d. Lithotomy 47. It refers to the manner of walking a. Gait b. Range of motion c. Flexion and extension d. Hopping 48. The nurse asked the client to read the Snellen chart. Which of the following is tested: a. Optic b. Olfactory c. Oculomotor d. Troclear 49. Another name for knee-chest position is: a. Genu-dorsalCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 16 b. Genu-pectoral c. Lithotomy d. Sim’s 50. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication a. Use a small gauge needle b. Apply ice on the injection site c. Administer at a 45° angle d. Use the Z-track technique ANSWERS for FUNDAMENTALS OF NURSING PART 1 1.d 11.a 2.b 3.d 4 b 5.b 6.b 7.c 8.a 9.b 10.b 12.c 13.c 14.c 15.c 16.a 17.d 18.b 19.b 20.c 21.b 22.a 23.b 24.a 25.c 26.c 27.b 28.b 29.a 30.a 31.b 32.a 33.c 34.c 35.a 36.a 37.b 38.b 39.a 40.a 41.a 42.d 43.b 44.c 45.a 46.c 47.a 48.a 49.b 50.dCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 17 FUNDAMENTALS OF NURSING PART 2 1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be… a. Maintain the patient on strict bed rest at all times b. Maintain the patient in an orthopneic position as needed c. Administer oxygen by Venturi mask at 24%, as needed d. Allow a 1 hour rest period between activities 2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as: a. Tachypnea b. Eupnca c. Orthopnea d. Hyperventilation 3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for: a. Instructing the patient about this diagnostic test b. Writing the order for this test c. Giving the patient breakfast d. All of the above 4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include: a. A ham and Swiss cheese sandwich on whole wheat bread b. Mashed potatoes and broiled chicken c. A tossed salad with oil and vinegar and olives d. Chicken bouillon 5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include: a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. b. Reporting an APTT above 45 seconds to the physician c. Assessing the patient for signs and symptoms of frank and occult bleeding d. All of the above 6. The four main concepts common to nursing that appear in each of the current conceptual models are: a. Person, nursing, environment, medicine b. Person, health, nursing, support systems c. Person, health, psychology, nursing d. Person, environment, health, nursing 7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is: a. Love b. Elimination c. Nutrition d. Oxygen 8. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do? a. Discourage them from making a decision until their grief has eased b. Listen to their concerns and answer their questions honestly c. Encourage them to sign the consent form right away d. Tell them the body will not be available for a wake or funeral 9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do? a. Complain to her fellow nurses b. Wait until she knows more about the unit c. Discuss the problem with her supervisor d. Inform the staff that they must volunteer to rotate 10. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? a. Continuity of patient care promotes efficient, cost-effective nursing care b. Autonomy and authority for planning are best delegated to a nurse who knows the patient well c. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 18 d. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. 11. If nurse administers an injection to a patient who refuses that injection, she has committed: a. Assault and battery b. Negligence c. Malpractice d. None of the above 12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for: a. Slander b. Libel c. Assault d. Respondent superior 13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with: a. Defamation b. Assault c. Battery d. Malpractice 14. Which of the following is an example of nursing malpractice? a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor. 15. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? a. Decreased blood pressure and heart rate and shallow respirations b. Quiet crying c. Immobility, diaphoresis, and avoidance of deep breathing or coughing d. Changing position every 2 hours 16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? a. Complete blood count b. Guaiac test c. Vital signs d. Abdominal girth 17. The correct sequence for assessing the abdomen is: a. Tympanic percussion, measurement of abdominal girth, and inspection b. Assessment for distention, tenderness, and discoloration around the umbilicus. c. Percussions, palpation, and auscultation d. Auscultation, percussion, and palpation 18. High-pitched gurgles head over the right lower quadrant are: a. A sign of increased bowel motility b. A sign of decreased bowel motility c. Normal bowel sounds d. A sign of abdominal cramping 19. A patient about to undergo abdominal inspection is best placed in which of the following positions? a. Prone b. Trendelenburg c. Supine d. Side-lying 20. For a rectal examination, the patient can be directed to assume which of the following positions? a. Genupecterol b. Sims c. Horizontal recumbent d. All of the above 21. During a Romberg test, the nurse asks the patient to assume which position? a. Sitting b. StandingCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 19 c. Genupectoral d. Trendelenburg 22. If a patient’s blood pressure is 150/96, his pulse pressure is: a. 54 b. 96 c. 150 d. 246 23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: a. Infection b. Hypothermia c. Anxiety d. Dehydration 24. Which of the following parameters should be checked when assessing respirations? a. Rate b. Rhythm c. Symmetry d. All of the above 25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported? a. Respiratory rate only b. Temperature only c. Pulse rate and temperature d. Temperature and respiratory rate 26. All of the following can cause tachycardia except: a. Fever b. Exercise c. Sympathetic nervous system stimulation d. Parasympathetic nervous system stimulation 27. Palpating the midclavicular line is the correct technique for assessing a. Baseline vital signs b. Systolic blood pressure c. Respiratory rate d. Apical pulse 28. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? a. Apical b. Radial c. Pedal d. Femoral 29. Which of the following patients is at greatest risk for developing pressure ulcers? a. An alert, chronic arthritic patient treated with steroids and aspirin b. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home c. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula d. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. 30. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation? a. Encourage the patient to increase her fluid intake to 200 ml every 2 hours b. Place a humidifier in the patient’s room. c. Continue administering oxygen by high humidity face mask d. Perform chest physiotheraphy on a regular schedule 31. The most common deficiency seen in alcoholics is: a. Thiamine b. Riboflavin c. Pyridoxine d. Pantothenic acid 32. Which of the following statement is incorrect about a patient with dysphagia? a. The patient will find pureed or soft foods, such as custards, easier to swallow than water b. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing c. The patient should always feed himself d. The nurse should perform oral hygiene before assisting with feeding. 33. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 20 a. Less than 30 ml/hour b. 64 ml in 2 hours c. 90 ml in 3 hours d. 125 ml in 4 hours 34. Certain substances increase the amount of urine produced. These include: a. Caffeine-containing drinks, such as coffee and cola. b. Beets c. Urinary analgesics d. Kaolin with pectin (Kaopectate) 35. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate? a. Encourage the patient to walk in the hall alone b. Discourage the patient from walking in the hall for a few more days c. Accompany the patient for his walk. d. Consuit a physical therapist before allowing the patient to ambulate 36. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be: a. Ineffective airway clearance related to thick, tenacious secretions. b. Ineffective airway clearance related to dry, hacking cough. c. Ineffective individual coping to COPD. d. Pain related to immobilization of affected leg. 37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be: a. “Don’t worry. It’s only temporary” b. “Why are you crying? I didn’t get to the bad news yet” c. “Your hair is really pretty” d. “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy” 38. An additional Vitamin C is required during all of the following periods except: a. Infancy b. Young adulthood c. Childhood d. Pregnancy 39. A prescribed amount of oxygen s needed for a patient with COPD to prevent: a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2 ) b. Circulatory overload due to hypervolemia c. Respiratory excitement d. Inhibition of the respiratory hypoxic stimulus 40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder? a. Lethargy b. Increased pulse rate and blood pressure c. Muscle weakness d. Muscle irritability 41. Which of the following nursing interventions promotes patient safety? a. Asses the patient’s ability to ambulate and transfer from a bed to a chair b. Demonstrate the signal system to the patient c. Check to see that the patient is wearing his identification band d. All of the above 42. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions? a. Side rails are ineffective b. Side rails should not be used c. Side rails are a deterrent that prevent a patient from falling out of bed. d. Side rails are a reminder to a patient not to get out of bed 43. Examples of patients suffering from impaired awareness include all of the following except: a. A semiconscious or over fatigued patient b. A disoriented or confused patient c. A patient who cannot care for himself at home d. A patient demonstrating symptoms of drugs or alcohol withdrawal 44. The most common injury among elderly persons is: a. Atheroscleotic changes in the blood vessels b. Increased incidence of gallbladder disease c. Urinary Tract InfectionCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 21 d. Hip fracture 45. The most common psychogenic disorder among elderly person is: a. Depression b. Sleep disturbances (such as bizarre dreams) c. Inability to concentrate d. Decreased appetite 46. Which of the following vascular system changes results from aging? a. Increased peripheral resistance of the blood vessels b. Decreased blood flow c. Increased work load of the left ventricle d. All of the above 47. Which of the following is the most common cause of dementia among elderly persons? a. Parkinson’s disease b. Multiple sclerosis c. Amyotrophic lateral sclerosis (Lou Gerhig’s disease) d. Alzheimer’s disease 48. The nurse’s most important legal responsibility after a patient’s death in a hospital is: a. Obtaining a consent of an autopsy b. Notifying the coroner or medical examiner c. Labeling the corpse appropriately d. Ensuring that the attending physician issues the death certification 49. Before rigor mortis occurs, the nurse is responsible for: a. Providing a complete bath and dressing change b. Placing one pillow under the body’s head and shoulders c. Removing the body’s clothing and wrapping the body in a shroud d. Allowing the body to relax normally 50. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to: a. Protect the patient from injury b. Insert an airway c. Elevate the head of the bed d. Withdraw all pain medicationsCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 22 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 2 1. B . When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia. 2. C . Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without effort. 3. C. A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test. 4. B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. 5. D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. 6. D. The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs. 7. D. Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs. 8. B. The brain-dead patient’s family needs support and reassurance in making a decision about organ donation. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. However, the family’s concerns must be addressed before members are asked to sign a consent form. The body of an organ donor is available for burial. 9. C. Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. In this case, the supervisor is the resource person to approach. 10. D. Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps. 11. A. Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery. 12. A. Oral communication that injures an individual’s reputation is considered slander. Written communication that does the same is considered libel. 13. D. Malpractice is defined as injurious or unprofessional actions that harm another. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. 14. A. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or heating pad to a patient without a physician’s order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. 15. C. An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deepCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 23 breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying. 16. B. To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is unrelated to blood loss. 17. D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. 18. C. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. 19. C. The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. In the lateral position, the patient lies on his side. 20. D. All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. 21. B. During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding. 22. A. The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54. 23. D. A slightly elevated temperature in the immediate preoperative or post operative period may result from the lack of fluids before surgery rather than from infection. Anxiety will not cause an elevated temperature. Hypothermia is an abnormally low body temperature. 24. D. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. 25. D. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. 26. D. Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Fever, exercise, and sympathetic stimulation all increase the heart rate. 27. D. The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. 28. C. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. 29. B. Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. 30. A. Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. 31. A. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. 32. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Feeding himself is a long-range expected outcome. Soft foods, Fowler’s or semi-Fowler’s position, and oral hygiene before eating should be part of the feeding regimen.COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 24 33. A. A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. 34. A. Fluids containing caffeine have a diuretic effect. Beets and urinary analgesics, such as pyridium, can color urine red. Kaopectate is an anti diarrheal medication. 35. C. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Accompanying him will offer moral support, enabling him to face the rest of the world. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Waiting to consult a physical therapist is unnecessary. 36. A. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. 37. D. “I know this will be difficult” acknowledges the problem and suggests a resolution to it. “Don’t worry..” offers some relief but doesn’t recognize the patient’s feelings. “..I didn’t get to the bad news yet” would be inappropriate at any time. “Your hair is really pretty” offers no consolation or alternatives to the patient. 38. B. Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. 39. D. Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Circulatory overload and respiratory excitement have no relevance to the question. 40. C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. 41. D. Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient’s ability to carry out these functions safely. Demonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient knows how to operate the equipment and encourages him to call for assistance when needed. Checking the patient’s identification band verifies the patient’s identity and prevents identification mistakes in drug administration. 42. D. Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. The other answers are incorrect interpretations of the statistical data. 43. C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. 44. D. Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. The other answers are diseases that can occur in the elderly from physiologic changes. 45. A. Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors 46. D. Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. These changes, in turn, increase the work load of the left ventricle. 47. D. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of the nerve fibers, usually begins in young adulthood and is marked by periods of remission and exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration. 48. C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patient’s death; however, she is not legally responsible for performing these functions. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. 49. B. The nurse must place a pillow under the decreased person’s head and shoulders to prevent blood from settling in the face and discoloring it. She is required to bathe only soiled areas of the body since theCOMPREHENSIVE NURSING REVIEW by R. C. REÑA | 25 mortician will wash the entire body. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. 50. A. Ensuring the patient’s safety is the most essential action at this time. The other nursing actions may be necessary but are not a major priority. FUNDAMENTALS OF NURSING PART 3 1. Which element in the circular chain of infection can be eliminated by preserving skin integrity? a. Host b. Reservoir c. Mode of transmission d. Portal of entry 2. Which of the following will probably result in a break in sterile technique for respiratory isolation? a. Opening the patient’s window to the outside environment b. Turning on the patient’s room ventilator c. Opening the door of the patient’s room leading into the hospital corridor d. Failing to wear gloves when administering a bed bath 3. Which of the following patients is at greater risk for contracting an infection? a. A patient with leukopenia b. A patient receiving broad-spectrum antibiotics c. A postoperative patient who has undergone orthopedic surgery d. A newly diagnosed diabetic patient 4. Effective hand washing requires the use of: a. Soap or detergent to promote emulsification b. Hot water to destroy bacteria c. A disinfectant to increase surface tension d. All of the above 5. After routine patient contact, hand washing should last at least: a. 30 seconds b. 1 minute c. 2 minute d. 3 minutes 6. Which of the following procedures always requires surgical asepsis? a. Vaginal instillation of conjugated estrogen b. Urinary catheterization c. Nasogastric tube insertion d. Colostomy irrigation 7. Sterile technique is used whenever: a. Strict isolation is required b. Terminal disinfection is performed c. Invasive procedures are performed d. Protective isolation is necessary 8. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? a. Using sterile forceps [Show More]

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