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Fundamentals of Nursing Part 2
Fundamentals of Nursing Part 2
a. Avoid bathing the patient until the condition is remedied, and notify the physician
b. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear
home-laundered sleepwear
c. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to
prevent infection
d. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the
patient, and apply lotion to the involved areas
2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the
distal to the proximal areas. This technique:
c. Stage II non-REM
d. Delta stage
4. The natural sedative in meat and milk products (especially warm milk) that can help
induce sleep is:
a. Flurazepam
b. Temazepam
c. Tryptophan
d. Methotrimeprazine
5. Nursing interventions that can help the patient to relax and sleep restfully include all of
the following except:
6. Restraints can be used for all of the following purposes except to:
a. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary
catheters
c. Discourage a patient from attempting to ambulate alone when he requires assistance for his
safety
7. Which of the following is the nurse’s legal responsibility when applying restraints?
c. Obtain a written order from the physician except in an emergency, when the patient must be
protected from injury to himself or others
9. A terminally ill patient usually experiences all of the following feelings during the anger
stage except:
a. Rage
b. Envy
c. Numbness
d. Resentment
10. Nurses and other health care provides often have difficulty helping a terminally ill
patient through the necessary stages leading to acceptance of death. Which of the following
strategies is most helpful to the nurse in achieving this goal?
11. Which of the following symptoms is the best indicator of imminent death?
12. A nurse caring for a patient with an infectious disease who requires isolation should
refers to guidelines published by the:
13. To institute appropriate isolation precautions, the nurse must first know the:
14. Which is the correct procedure for collecting a sputum specimen for culture and
sensitivity testing?
a. Have the patient place the specimen in a container and enclose the container in a plastic bag
b. Have the patient expectorate the sputum while the nurse holds the container
d. Offer the patient an antiseptic mouthwash just before he expectorate the sputum
16. The best way to decrease the risk of transferring pathogens to a patient when removing
contaminated gloves is to:
c. Gently pull just below the cuff and invert the gloves when removing them
17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning,
and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This
usually indicates:
a. Infection
b. Infiltration
c. Phlebitis
d. Bleeding
18. To ensure homogenization when diluting powdered medication in a vial, the nurse
should:
19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for
self-injection. The patient’s first priority concerning self-injection in this situation is to:
c. Check the syringe to verify that the nurse has removed the prescribed insulin dose
20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal
saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
a. 25 gtt/minute
b. 37 gtt/minute
c. 50 gtt/minute
d. 60 gtt/minute
21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1
ml. How many milliliters should the nurse administer?
a. 0.5 ml
b. 0.75 ml
c. 1 ml
d. 2 ml
22. How should the nurse prepare an injection for a patient who takes both regular and NPH
insulin?
a. Draw up the NPH insulin, then the regular insulin, in the same syringe
b. Draw up the regular insulin, then the NPH insulin, in the same syringe
23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he
vomits. What should the nurse do first?
24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:
25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable
initially when supervising her former peers. She can best decrease this discomfort by:
b. Making changes after evaluating the situation and having discussions with the staff.
c. Telling the staff nurses that she is making changes to benefit their performance
1. Answer – D.
Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the
nurse should provide adequate hydration through fluid intake, use nonirritating soaps or no soap
when bathing the patient, and lubricate the patient’s skin with lotion. Bathing may be limited but
need not be avoided entirely. The attending physician and dietitian may be consulted for
treatment, but home-laundered items usually are not necessary.
2. Answer – C.
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous
stasis. It improves circulation but does not result in vasoconstriction. The nurse can assess the
patient’s condition throughout the bath, regardless of washing technique, and should feel no
strain while bathing the patient.
3. Answer – B.
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be
awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. Non-
REM sleep is a deep, restful sleep without dreaming. Delta stage, or slow-wave sleep, occurs
during non-REM Stages III and IV and is often equated with quiet sleep.
4. Answer – C.
5. Answer – A.
Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching
television, reading, and massage usually will relax the patient, helping him to fall asleep.
6. Answer – D.
By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather
than prevent it. The other choices are valid reasons for using restraints.
7. Answer – D.
When applying restraints, the nurse must document the type of behavior that prompted her to
use them, document the type of restraints used, and obtain a physician’s written order for the
restraints.
8. Answer – C.
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression,
and acceptance. The patient may move back and forth through the different stages as he and his
family members react to the process of dying, but he usually goes through all of these stages to
reach acceptance.
9. Answer – C.
Numbness is typical of the depression stage, when the patient feels a great sense of loss. The
anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why
me?”
10. Answer – C.
According to thanatologists, reflecting on the significance of death helps to reduce the fear of
death and enables the health care provider to better understand the terminally ill patient’s
feelings. It also helps to overcome the belief that medical and nursing measures have failed, when
a patient cannot be cured.
11. Answer – C.
Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles become
weak and atonic, and periods of apnea occur during respiration.
12. Answer – B.
The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for
patients who require isolation. The National League of Nursing’s (NLN’s) major function is
accrediting nursing education programs in the
United States. The American Medical Association (AMA) is a national organization of physicians.
The American Nurses’ Association (ANA) is a national organization of registered nurses.
13. Answer – A.
Before instituting isolation precaution, the nurse must first determine the organism’s mode of
transmission. For example, an organism transmitted through nasal secretions requires that the
patient be kept in respiratory isolation, which involves keeping the patient in a private room with
the door closed and wearing a mask, a grown, and gloves when coming in direct contact with the
patient. The organism’s Gram-straining characteristics reveal whether the organism is gram-
negative or gram-positive, an important criterion in the physician’s choice for drug therapy and
the nurse’s development of an effective plan of care. The nurse also needs to know whether the
organism is susceptible to antibiotics, but this could take several days to determine; if she waits
for the results before instituting isolation precautions, the organism could be transmitted in the
meantime. The patient’s susceptibility to the organism has already been established. The nurse
would not be instituting isolation precautions for a non infected patient.
14. Answer – C.
Placing the specimen in a sterile container ensures that it will not become contaminated. The
other answers are incorrect because they do not mention sterility and because antiseptic
mouthwash could destroy the organism to be cultured (before sputum collection, the patient
may use only tap water for nursing the mouth).
15. Answer – D.
16. Answer – C.
Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They
should than be placed in a plastic bag with soiled dressings and discarded in a soiled utility room
garbage pail (double bagged). The other choices can spread pathogens within the environment.
17. Answer – C.
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and
symptoms of phlebitis. Infection is less likely because no drainage or fever is present. Infiltration
would result in swelling and pallor, not erythema, near the insertion site. The patient has no
evidence of bleeding.
18. Answer – B.
Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of
a powdered medication. Shaking the vial vigorously can break down the medication and alter its
pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough
homogenization of the powder and the solvent.
19. Answer – C.
When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to
validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site
with alcohol before injecting the insulin.
20. Answer – A. 25 gtt/minute
22. Answer – B.
Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the
shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin
(NPH) to ensure accurate measurements.
23. Answer – C.
After a patient has vomited, the nurse must inspect the emesis to document color, consistency,
and amount. In this situation, the patient recently ingested medication, so the nurse needs to
check for remnants of the medication to help determine whether the patient retained enough of
it to be effective. The nurse must then notify the physician, who will decide whether to repeat the
dose or prescribe an antiemetic.
24. Answer – B.
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate
kidney failure. This must be corrected while the patient is in the acute state so that appropriate
fluids, electrolytes, and medications can be administered and excreted. Indwelling
catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine.
25. Answer – B.
A new assistant nurse manager should not make changes until she has had a chance to evaluate
staff members, patients, and physicians. Changes must be planned thoroughly and should be
based on a need to improve conditions, not just for the sake of change. Written assignments allow
all staff members to know their own and others responsibilities and serve as a checklist for the
manager, enabling her to gauge whether the unit is being run effectively and whether patients are
receiving appropriate care. Telling the staff nurses that she is making changes to benefit their
performance should occur only after the nurse has made a thorough evaluation. Evaluations are
usually done on a yearly basis or as needed.
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