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Nursing 101 Fundamentals of Nursing
Practice Exam 1, Part 1
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 - ansA. Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site. 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 D. Close the patient's door from 9pm to 7am - ansC. Give the patient a glass of warm milk before bedtime Warm milk will relax the patient because it contains tryptophan, a natural sedative. A skin lesion which is fluid-filled, less than 1 cm in size is called: A. Papule B. Vesicle C. Bulla D. Macule - ansB. Vesicle Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox). A sudden redness of the skin is known as: A. Flush B. Cyanosis C. Jaundice D. Pallor - ansA. 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. According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen? A. Safety B. Activity C. Love D. Self esteem - ansB. Activity According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen, shelter, food, water, thirst, sleep and temperature maintenance. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? A. Low blood pressure B. Warm, dry skin C. Decreased serum sodium levels D. Decreased urine output - ansD. Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: A. 3 months B. 6 months C. 9 months D. 1 year - ansB. 6 months Chronic pain is usually defined as pain lasting longer than 6 months. Constipation is a common problem for immobilized patients because of: A. Decreased tightening of the anal sphincter B. An increased defecation reflex C. Decreased peristalsis and positional discomfort D. Increased colon motility - ansC. Decreased peristalsis and positional discomfort Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters. During a change-of-shift report, it would be important for the nurse relinquishing 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."
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. Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor - ansB. Nurse and patient Although diagnosing is basically the nurse's responsibility, input from the patient is essential to formulate the correct nursing diagnosis. If a patient sues a nurse for malpractice, the patient must be able to prove: A. Error, proximal cause, and lack of concern B. Error, injury and proximal cause C. Injury, error and assault D. Proximal cause, negligence and nurse error - ansB. Error, injury and proximal cause Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two. It is the gradual decrease of the body's temperature after death: A. Livor mortis B. Rigor mortis C. Algor mortis D. none of the above - ansC. 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. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: 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 - ansC. 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. Kussmaul's breathing is: A. Shallow breaths interrupted by apnea
B. Prolonged gasping inspiration followed by a very short, usually inefficient expiration C. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea D. Increased rate and depth of respiration - ansD. Increased rate and depth of respiration Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biot's breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing. 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: A. Croupette B. Nasal cannula C. Nasal catheter D. Partial rebreathing mask - ansB. Nasal cannula The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink. Newborn screening is done to every newborn in the Philippines. This is an example of: A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Rehabilitation - ansB. Secondary prevention Promotion of early detection and early treatment of the disease is under secondary prevention. Example, breast self exam, TB screening, genetic counseling. 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 - ansB. 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. One of Nurse Cathy's co-workers is Annie who is flexible in any given situation. Annie is performing her duties well without supervision but still needs more experience and practice to develop a consciously planned nursing care. According to Patricia Benner's category in specialization in nursing, Annie is a/an: A. Novice
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 average daily amount of urine excreted by an adult is: A. 500 to 600 ml B. 800 to 1,400 ml C. 1,000 to 1,200 ml D. 1,500 to 2,000 ml - ansD. 1,500-2,000 ml An adult's average urine output ranges between 1,500 and 2,000 ml/day. The clinical instructor is discussing about the Nursing Process. She mentioned that when a cluster of actual or high-risk diagnosis are present because of a certain situation it is called: A. Wellness nursing diagnosis B. Actual nursing diagnosis C. Syndrome nursing diagnosis D. Risk nursing diagnosis - ansC. Syndrome nursing diagnosis Presence of both actual and high-risk diagnosis is called a syndrome nursing diagnosis. 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 correct site at which to verify a radial pulse measurement is the: A. Brachial artery B. Apex of the heart C. Temporal artery D. Inguinal site - ansB. Apex of the heart The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly. 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 - ansB. 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. The nurse is aware that Bell's palsy affects which cranial nerve? A. 2nd CN (Optic)
B. 3rd CN (Occulomotor) C. 4th CN (Trochlear) D. 7th CN (Facial) - ansD. 7th CN (Facial) Bells' palsy is the paralysis of the motor component of the 7th cranial nerve, resulting 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. The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular - ansA. Wheezes Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. The nurse should take a rectal temperature of a patient who has: A. His arm in a cast B. Nasal packing C. External hemorrhoids D. Gastrostomy feeding tubes - ansB. Nasal packing A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and those who have history of seizures, etc.). However, a rectal temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea) 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 - ansB. 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. The term gavage indicates: A. Administration of a liquid feeding into the stomach B. Visual examination of the stomach C. Irrigation of the stomach with a solution D. A surgical opening through the abdomen to the stomach - ansA. Administration of a liquid feeding into the stomach
C. Disconnect the catheter from the tubing and get urine D. Aspirate urine from the tubing port using a sterile syringe - ansD. 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. When assessing a patient's level of consciousness, which type of nursing intervention is the nurse performing? A. Independent B. Dependent C. Collaborative D. Professional - ansA. Independent 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. 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 - ansD. 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. 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 - ansD. Lung Resonance is loud, low-pitched and long duration that's heard most commonly over an air-filled tissue such as a normal lung. Which communication skills is most effective in dealing with covert communication? A. Clarification B. Listening C. Evaluation D. Validation - ansD. Validation
Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer's perceptions through feedback, interpretation and clarification. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? A. Oriented to date, time and place B. Clear breath sounds C. Capillary refill greater than 3 seconds and buccal cyanosis D. Hemoglobin of 13 g/dl - ansC. Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data. Which of the following is a nursing diagnosis? A. Hypothermia B. Diabetes Mellitus C. Angina D. Chronic Renal Failure - ansA. Hypothermia Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses. 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 - ansA. 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 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 - ansC. Making of individualized patient care
