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Fundamentals of Nursing Practice Exam 4 (PM)
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1. A sudden redness of the skin is known as:
2. The term gavage indicates:
- Administration of a liquid feeding into the stomach
- Visual examination of the stomach
- Irrigation of the stomach with a solution
- A surgical opening through the abdomen to the stomach
3. A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action?
- Administer a sedative at bedtime, as ordered by the physician
- Ambulate the patient for 5 minutes before he retires
- Give the patient a glass of warm milk before bedtime
- Close the patient’s door from 9pm to 7am
4. Which of the following nursing theorists dveloped a conceptual model based on the belief that all persons strive to achieve self-care?
- Martha Rogers
- Dorothea Orem
- Florence Nightingale
- Cister Callista Roy
5. Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus?
- Martha Rogers
- Dorothea Orem
- Florence Nightingale
- Sister Callista Roy
6. Which of the following questions is most appropriate to ask when interviewing a potential candidate fo an RN position?
- What was your last nursing experience?
- Are you willing to do overtime on weekends?
- How many children do you have?
- Do you plan to get pregnant?
7. If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the nurse?
- The private attending physician
- The nursing supervisor
- The hospital
- All of the above
8. Which of the following may be considered a patient’s right?
- The right to euthanasia
- The right to refuse treatment
- The right to ignore hospital regulations
- The right to refuse to pay for what the patient considers to be inferior service.
9. If a patient sues a nurse for malpractice, the patient must be able to prove:
- Error, proximal cause, and lack of concern
- Error, injury and proximal cause
- Injury, error and assault
- Proximal cause, negligence and nurse error
10. Which communication skills is most effective in dealing with covert communication?
11. Which of the following qualities are relevant in documenting patient care?
- Accuracy and conciseness
- Thoroughness and currentness
- All of the above
12. The usual sequence for assessing the bowel is:
- Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
- Right lower lobe, right upper lobe, left upper lobe, left lower lobe
- Right hypochondriac, left hypochondriac and umbilical regions
- Rectum, pancreas, stomach and liver
13. The nurse should take a rectal temperature of a patient who has:
- His arm in a cast
- Nasal packing
- External hemorrhoids
- Gastrostomy feeding tubes
14. Blood pressure measurement is an important part of the patient’s data base. It is considered to be:
- The basis of the nursing diagnosis
- Objective data
- An indicator of the patient’s well being
- Subjective data
15. Postural drainage to relieve respiratory congestion should take place:
- Before meals
- After meals
- At the nurse’s convenience
- At the patient’s convenience
16. The correct site at which to verify a radial pulse measurement is the:
- Brachial artery
- Apex of the heart
- Temporal artery
- Inguinal site
17. S1 is heard best at the:
- 5th left intercoastal space along the midclavicular line
- 3rd intercoastal space to the left of the midclavicular line
- Second right intercoastal space at the sternal border
- Second left intercoastal space at the sternal border
18. The nurse’s main priority when caring foar a patient with hemiplegia?
- Educating the patient
- Providing a safe environment
- Promoting a positive self-image
- Helping the patient accept the illness
19. Constipation is a common problem for immobilized patients because of:
- Decreased peristalsis and positional discomfort
- An increased defacation reflex
- Decreased tightening of the anal sphincter
- Increased colon motility
20. Antiembolism stockings are used primarily to:
- Promote venous circulation
- Provide external warmth
- Prevent dependent edema
- Hold foot dressings
21. To promote correct anatomic alignment in a supine patient, the nurse should:
- Place the patient’s feet in dorsiflexion
- Place a pillow under the patient’s knees
- Hyperextend the patient’s neck
- Adduct the patient’s shoulder
22. An appropriate interdependent intervention to prevent thrombophebitis would be:
- Elevate the knee gatch of the bed
- Massage the legs vigorously
- Apply antiembolism stockings to both legs.
- Encourage the patient to sit with his knees crossed
23. The average daily amount of urine excreted by an adult is:
- 500 to 600 ml
- 800 to 1,400 ml
- 1,000 to 1,200 ml
- 1,500 to 2,000 ml
24. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after oxygen?
- Self esteem
25. Mr. Jose is admitted to the hospitalwith 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:
- Nasal Cannula
- Nasal catheter
- Partial rebreathing mask
Answers and Rationales
- Answer : (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 sclerae 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.
- Answer :(A) Administration of a liquid feeding into the stomach. Gavage is the administration of a liquid feeding into the stomach
- Answer :(C) Give the patient a glass of warm milk before bedtime. Warm milk will relax the patient because it contains tryptophan, a natural sedative.
- Answer :(B) Dorothea Orem. Dorothea Orem’s conceptual model is based on the premise that all persons need to achieve self-care. She also views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.
- Answer :(A) Martha Rogers. Martha Roger’s life process model views man as an evolving creature interacting with the environment in an open, adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his environment.
- Answer :(A) What was your last nursing experience?. An interviewer’s question should center on the applicant’s qualifications for the position. Questions about the applicant’s personal life are inappropriate and may be illegal.
- Answer :(C) The hospital. Under the master servant rule (also known as the doctrine or respondeat superior), when a person is injured by an employee as a result of negligence in the course of the employee’s work, the employer is responsible to the injured person.
- Answer :(B) The right to refuse treatment. Under the bill of rights law, the patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be informed of the medical consequences of his action.
- Answer :(B) 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.
- Answer :(A) 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.
- Answer :(D) All of the above. Documentation should leave no room for misinterpretation. Thus, the nurse must ensure that all information pertinent to patient care is reworded accurately, concisely and thoroughly. The information must be up-to-date and well organized.
- Answer :(A) Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant. This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and the umbilical area are three of the nine regions of the abdomen.
- Answer :(B) 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)
- Answer :(B) Objective data. Objective data are those such as BP, which can be measured or perceived by someone other than the patient. Subjective data are those such as pain, which only the patient can perceive.
- Answer :(A) Before meals. 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.
- Answer :(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.
- Answer :(A) 5th left intercoastal space along the midclavicular line. The S1 heart sound is best heard at the apex of the heart, at the fifth intercoastal space along the midclavicular line. (An infant’s apex is located at the third or fourth intercoastal space just to the left of the midclavicular line)
- Answer :(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.
- Answer :(A) Decreased peristalsis and positional discomfort. Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters.
- Answer :(A) Promote venous circulation. Antiembolism stockings are elastic stockings designed to maintain compression of small veins and capillaries in the legs.
- Answer :(A) Place the patient’s feet in dorsiflexion. Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs)
- Answer :(C) Apply antiembolism stockings to both legs.. Antiembolism stockings increase venous return to the heart, which helps prevent thromboplebitis.
- Answer :(D) 1,500 to 2,000 ml. An adult’s average urine output ranges between 1,500 and 2,000 ml/day.
- Answer :(A) Activity. According to Maslow, activity is one of the man’s most basic physiologic needs, along with oxygen, shelter, food, water, erst, sleep and temperature maintenance.
- Answer :(B) Nasal Cannula. The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.