Download Fundamentals of Nursing Practice Exam 1: Multiple Choice Questions and more Exams Nursing in PDF only on Docsity!
Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 1
- During a physical assessment, the nurse closes and door and provides drape to promote privacy.The nurse is performing her role as a/an Correct Answer(s) A. Advocate B. Communicator C. Change agent D. Caregiver Correct Answer(s) D. Caregiver The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the client. Identifying the need and problems of the client and communicating it to other members of the health team is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their BEHAVIOR.
- During the nursing rounds Nurse Cathy is instructing the patient to avoid smoking to prevent the worsening of respiratory problems.The patient asked about the things that he can do when feelings of wanting to smoke arises. The nurse enumerates ways of dealing the situation.This is an example of a nurse's role as a/an: A. Advocate B. Clinician C. Change agent D. Caregiver Correct Answer(s) C. Change agent
As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. As an advocate the nurse intercedes or works on behalf of the client. As a clinician, the nurse would use technical expertise to administer nursing care. The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically.
- Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based on Benner's theory she is a/an: A. Novice B. Expert C. Competent D. Advanced beginner Correct Answer(s) B. Expert The ability to perceive something without further evidence is the development of intuition and is seen in Expert nurses. A novice nurse is governed by rules and usually inflexible. Competent nurses are planning nursing care consciously. Advanced beginners demonstrate acceptable performance.
A. Wellness nursing diagnosis B. Actual nursing diagnosis C. Syndrome nursing diagnosis D. Risk nursing diagnosis Correct Answer(s) C. Syndrome nursing diagnosis Presence of both actual and high-risk diagnosis is called a syndrome nursing diag- nosis. Wellness nursing diagnosis focuses on the clinical judgment on an individual from a specific to higher level of wellness. Actual diagnoses are clinical judgment of the nurse that is validated. A risk diagnosis is based on the clinical are based on clinical judgment that the client may develop vulnerability to the problem.
- The nurse in charge measures a patient's temperature at 101 degrees F. What is the equivalent centigrade temperature? A. 36.3 degrees C B. 37.95 degrees C
C. 40.03 degrees C D. 38.01 degrees C Correct Answer(s) B. 37. To convert °F to °C use this formula, ( °F - 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.
- During a change-of-shift report, it would be important for the nurse relin- quishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? A. That the patient verbalized, "My headache is gone." B. That the patient's barium enema performed 3 days ago was negative C. Patient's NGT was removed 2 hours ago D. Patient's family came for a visit this morning. Correct Answer(s) C. Patient's NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patient's condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report
- A client is receiving 115 ml/hr of continuous IVF.The nurse notices that the venipuncture site is red and swollen.Which of the following interventions would the nurse perform first? A. Stop the infusion B. Call the attending physician C. Slow that infusion to 20 ml/hr D. Place a cold towel on the site Correct Answer(s) A. Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped
B. Diagnosing, assessing, planning, implementing, evaluating C. Assessing, diagnosing, planning, implementing, evaluating D. Planning, evaluating, diagnosing, assessing, implementing Correct Answer(s) C. Assessing, diagnosing, planning, implementing, evaluating The correct order of the nursing process is assessing, diagnosing, planning, imple- menting, evaluating.
- Which of the following is the most important purpose of planning care with a patient? A. Development of a standardized NCP. B. Expansion of the current taxonomy of nursing diagnosis C. Making of individualized patient care D. Incorporation of both nursing and medical diagnoses in patient care Correct Answer(s) C. Making of individualized patient care To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.
- What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? A. Use sterile gloves when obtaining urine B. Open the drainage bag and pour out the urine C. Disconnect the catheter from the tubing and get urine D. Aspirate urine from the tubing port using a sterile syringe Correct Answer(s) D. Aspirate urine from the tubing port using a sterile syringe The nurse should aspirate the urine from the port using a sterile syringe to obtain a
urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.
- Jake is complaining of shortness of breath. The nurse assesses his respi- ratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means Correct Answer(s) ÿ A. Pulse rate greater than 100 beats per minute B. Blood pressure of 140/ C. Respiratory rate greater than 20 breaths per minute D. Frequent bowel sounds Correct Answer(s) C. Respiratory rate greater than 20 breaths per minute A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.
sodium and water. This results to decreased urine output.
- When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? A. 30 degrees B. 90 degrees C. 45 degrees D. 0 degree Correct Answer(s) D. 0 degree The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings.
- Which of the following is inappropriate nursing action when administering NGT feeding?
A. Place the feeding 20 inches above the point of insertion of NGT B. Introduce the feeding slowly C. Instill 60ml of water into the NGT after feeding D. Assist the patient in fowler's position Correct Answer(s) A. Place the feeding 20 inches above the point of insertion of NGT The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting
- During application of medication into the ear, which of the following is inappropriate nursing action? A. In an adult, pull the pinna upward B. Instill the medication directly into the tympanic membrane C. Warm the medication at room or body temperature D. Press the tragus of the ear a few times to assist flow of medication into the ear canal Correct Answer(s) B. Instill the medication directly into the tympanic membrane During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
- Kussmaul's breathing is Correct Answer(s) A. Shallow breaths interrupted by apnea B. Prolonged gasping inspiration followed by a very short, usually inefficient expiration
in facial sag, inability to close the eyelid or the mouth, drooling, flat naso-labial fold and loss of taste on the affected side of the face.
- When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ? A. Thigh B. Liver C. Intestine D. Lung Correct Answer(s) D. Lung Resonance is loud, low-pitched and long duration that's heard most commonly over an air-filled tissue such as a normal lung.
- To assess the adequacy of food intake, which of the following assessment parameters is best used? A. Food preferences B. Regularity of meal times C. 3-day diet recall D. Eating style and habits Correct Answer(s) C. 3-day diet recall 3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client.
- Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than Correct Answer(s) A. 3 months B. 6 months
C. 9 months D. 1 year Correct Answer(s) B. 6 months Chronic pain is usually defined as pain lasting longer than 6 months.
- It is the gradual decrease of the body's temperature after death Correct Answer(s) A. Livor mortis B. Rigor mortis C. Algor mortis D. none of the above Correct Answer(s) C. Algor mortis Algor mortis is the decrease of the body's temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.
Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.
- Which of the following is a nursing diagnosis? A. Hypothermia B. Diabetes Mellitus C. Angina D. Chronic Renal Failure Correct Answer(s) A. Hypothermia Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.
- A skin lesion which is fluid-filled, less than 1 cm in size is called Correct Answer(s) A. Papule
B. Vesicle C. Bulla D. Macule Correct Answer(s) B. Vesicle Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).
- S1 is heard best at the Correct Answer(s) A. 5th left intercostal space along the midclavicular line B. 3rd intercostal space to the left of the midclavicular line C. Second right intercostal space at the sternal border D. Second left intercostal space at the sternal border Correct Answer(s) A.5th left intercostal space along the midclavicular line The S1 heart sound is best heard at the apex of the heart, at the fifth intercostal space along the midclavicular line. (An infant's apex is located at the third or fourth intercostal space just to the left of the midclavicular line)
- The correct site at which to verify a radial pulse measurement is the Correct Answer(s) A. Brachial artery B. Apex of the heart C. Temporal artery D. Inguinal site Correct Answer(s) B. Apex of the heart The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.
- To promote correct anatomic alignment in a supine patient, the nurse
Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The patient's safety supersedes the convenience in scheduling this procedure.
- Mr. Jose is admitted to the hospital with a diagnosis of pneumonia and COPD.The physician orders an oxygen therapy for him.The most comfortable method of delivering oxygen to Mr. Jose is by Correct Answer(s) A. Croupette B. Nasal cannula C. Nasal catheter D. Partial rebreathing mask Correct Answer(s) B. Nasal cannula The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.
- The nurse's main priority when caring for a patient with hemiplegia? A. Educating the patient B. Providing a safe environment C. Promoting a positive self-image D. Helping the patient accept the illness Correct Answer(s) B. Providing a safe environment A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse's main priority.
- A sudden redness of the skin is known as Correct Answer(s) A. Flush B. Cyanosis
C. Jaundice D. Pallor Correct Answer(s) A. Flush Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclera caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.
- A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action? A. Administer a sedative at bedtime, as ordered by the physician B. Ambulate the patient for 5 minutes before he retires C. Give the patient a glass of warm milk before bedtime
