C. DiagnosisD. Evaluation
The basic difference between nursing diagnoses and collaborative problems is thatA. nurses manage collaborative problems using physician-prescribed interventions.B. collaborative problems can be managed by independent nursing interventions.C. nursing diagnoses incorporate physician-prescribed interventions.D. nursing diagnoses incorporate physiologic complications that nurses monitor to detect change in status.Situation – Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in themenopausal stage.
Instruction on health promotion regarding urinary elimination is important. Which would you include?A. Hold urine as long as she can before emptying the bladder to strengthen her sphincter musclesB. If burning sensation is experienced while voiding, drink pineapple juiceC. After urination, wipe from anal area up towards the pubisD. Tell client to empty the bladder at each voiding
Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predisposeher to constipation?A. inhibition of the parasympathetic reflexB. weakness of sphincter muscles of anusC. loss of tone of the smooth muscles of the colonD. decreased ability to absorb fluids in the lower intestines
The nurse understands that one of these factors contributes to constipation:A. excessive exerciseB. high fiber dietC. no regular time for defecation dailyD. prolonged use of laxatives
You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adultwould be:A. tip of the nose to the base of the neckB. the distance from the tip of the nose to the middle of the neckC. the distance from the tip of the nose to the tip of the ear lobeD. eight to ten inchesSituation– Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of hypertension, flushed face, severeheadache, and nausea. You are doing the initial assessment of vital signs.
You are to measure the client’s initial blood pressure reading by doing all of the following EXCEPT:A. Take the blood pressure reading on both arms for comparisonB. Listen to and identify the phases of Korotkoff’s soundC. Pump the cuff to around 50 mmHg above the point where the pulse is obliteratedD. Observe procedures for infection control
A pulse oximeter is attached to Mr. Dizon’s finger to:A. Determine if the client’s hemoglobin level is low and if he needs blood transfusionB. Check level of client’s tissue perfusionC. Measure the efficacy of the client’s anti-hypertensive medicationsD. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
In which type of shock does the patient experiences a mismatch of blood flow to the cells?A. Distributive C. HypovolemicB. CardiogenicD. Septic
The preferred route of administration of medication in the most acute care situations is which of the following routes?A. Intravenous C. SubcutaneousB. EpiduralD. Intramuscular
After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:A. inconsistentB. low systolic and high diastolicC. higher than what the reading should beD. lower than what the reading should be