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TEST B: NURSING PRACTICE I

ANSWERS AND RATIONALES

1. c- Epinephrine is used as bronchodilator in asthma or allergic reactions. It relieves


bronchial spasm and allows increased oxygen intake. Other significant body responses
to epinephrine include increased myocardial contractility and metabolism, and
increased blood clotting.
2. b- In preparing medications, first, it is necessary to check the label and expiration date
to prevent medication error. In withdrawing medication from ampule, flick the upper
stem to bring all the medication down to the main portion of the ampule. The sterile
gauze wrapped around the neck of the ampule will protect the fingers from the broken
glass.
3. d- If the client has more than ½ inch of adipose tissue in the injection site, it would be
safe to administer the injection at a 45-90-degree angle with the skin spread. If the
client is thin or lean and lacks adipose tissue, the subcutaneous injection should be
given with the skin pinched at a 45-60-degree angle. Option a is an administration of a
drug into the dermal layer of the skin. Options b and c are done in a n intramuscular
injection.
4. d- The type of syringe used for subcutaneous injections depends on the medication to
be given. Generally, a 2-ml syringe (Gauge 25-27) is used for most subcutaneous
injections. Needle sizes and lengths are selected based on the client’s mass, the
intended angle of insertion and planned site.
5. b- The subcutaneous route will allow slower absorption of a medication compared with
either the IM or IV route.
6. b- A study on the given topic is an example a qualitative research. The intent of this
research is to thoroughly describe and explain a phenomenon. Quantitative research
progresses through systematic logical steps and collect numerical information.
7. c- In non-experimental design, the investigator does no manipulation of the
independent variable. Experimental design manipulates the independent variable by
administering an experimental treatment to some subjects. Quasi-experimental
design manipulates the independent variable but without the randomization or control
that characterizes true experiments. Quantitative design progresses through
systematic logical steps and collect numerical information.
8. d-Nurses are actively generating, publishing, and applying research in practice to
improve client care and enhance nursing’s scientific knowledge base.
9. b- A literature review (or overview) is a summary and analysis of current knowledge
about a particular topic or area of inquiry. It helps uncover ideas about which variables
are important in a given field of study. It provides information about what research
has already been done and what needs to be done. It reveals demonstrated and/or
theorized relationships among variables that the researcher is interested in or wishes
to study.
10. b- Right to compensation does not play an important role in safeguarding the client.
The client must be informed and should understand the consequences of consenting
to serve as research subjects. He has the right not to be harmed, right to full
disclosure, right of self-determination and right of privacy and confidentiality.
11. b- The semi-fowler’s/fowler’s position allows maximum lung expansion. In sitting
position, the abdominal organs are not pressing on the diaphragm. High-fowler’s
and/or sitting positions are used during percussion over congested lung areas to
mechanically dislodge tenacious secretions from bronchial walls.
12. c- The amount of fluid intake before and after the procedure is being assessed and
documented if a patient has urinary and fluid and electrolytes problem. Options a, b,
and d are included in documenting outcomes for patients with respiratory problem.
13. c- Teaching the significant others how to perform chest percussion, vibration and
postural drainage is of least priority. The doctor’s order regarding position restrictions
should be checked to prevent discomfort or any untoward symptoms if the procedure
is conducted. The amount of fluid/food intake and the RR, breath sounds and location
of congestion are important considerations to be assessed prior to the procedure.
14. d- It is important to consider the time of last food and fluid intake of the client before
postural drainage and percussion. It is best to avoid hours shortly after meals because
postural drainage at these times can be tiring. Both procedures can induce vomiting if
done right after meals.
15. b- Percussion is a forceful striking of the skin with cupped hands. Cupped hands trap
the air against the chest, the trapped air sets up vibrations through the chest wall to
the secretions. Vibrations, on the other hand, is used after percussion to increase the
turbulence of the exhaled air and thus loosen thick secretions
16. a- In order to identify the client’s perceived needs, it is essential to conduct an
interview and listen carefully to the client’s chief complaints and symptoms. This
would facilitate nurse-patient interaction and would enable the nurse to design
nursing care plan according to the client’s health priority.
17. d- After gathering and establishing the patient’s nursing needs, the next step is to
establish priority and implement therapeutic actions corresponding to the set priority
needs. Options a, b, and c are also appropriate but can be done later.
18. b- The phrase “trouble going to sleep” is vague. Reflecting what the patient wants to
convey would allow the nurse to plan appropriately and intervene properly.
19. c- The best and immediate nursing intervention for patients with pedal edema is to
elevate the lower extremities to promote venous return. Edema is most common in
parts of the body positioned below the heart.
20. C- Walking the client to the hospital exit is not included in the discharge plan. The
effective nursing actions when preparing the client for discharge include giving
instructions about compliance or adherence to medication regimen, making final
physical assessment to ensure that the client’s needs are met and proper
documentation.
21. d- Preoperative teaching is a vital part of nursing care and reduces client’s anxiety.
Explaining the procedures at the level of the client’s understanding will minimize
anxiety. Furthermore, the nurse provides support by actively listening and providing
accurate information to rectify any misperceptions.
22. c- The client is in the stage of anger in Kubler-Ross’s Stage of Grieving. The client may
direct anger about matters that normally would not bother her. In denial stage, the
client refuses to believe that loss is happening. The third stage of grieving is
bargaining, the client expresses feeling of guilt or fear of punishment. Acceptance is
the last stage, in which, the client comes to terms with loss.
23. d-This statement is trying to validate the client’s feelings and a therapeutic approach.
This would enable the client to share her concerns/fear with the nurse. Options a, b,
and c may blck therapeutic communication.
24. a- The nurse should use individual reflective exercises and must learn how to control
her feelings. Once she has developed a clear understanding and awareness of self, the
nurse can respect and avoid projecting her own belief onto others. The self-aware
nurse is able to suspend judgment and focus on the needs of the client, even if they
differ from those of the nurse.
25. c- Self-awareness refers to the relationship between one’s perception of herself and
others’ perception of her. The nurse should use individual reflective exercises. Once
she has developed a clear understanding and awareness of self, the nurse can respect
and avoid projecting her own belief onto others. The self-aware nurse is able to
suspend judgment and focus on the needs of the client, even if they differ from those
of the nurse.
26. d-To promote urinary elimination, instruct the clients to empty the bladder completely
at each voiding. To maintain asepsis, instruct female clients to wipe from front to back
(urinary meatus to anus). Furthermore, instruct to respond to the urge to void as soon
as possible to prevent urinary retention. Limit caffeine, alcohol, citrus juices for clients
with urge or stress incontinence.
27. c- The muscle tone of the intestines decreases by age, causing a decrease in
peristalsis and elimination. This may lead to indigestion and constipation.
28. d- Chronic use of laxatives or enemas contributes to constipation. It is important to
define constipation in relation to the person’s regular elimination pattern. Some
normally defecate only a few times a week. Others defecate more than once a day.
Careful assessment of the person’s habits is necessary before diagnosis of
constipation is made. Options a and b will not lead to constipation.
29. d- Pelvic muscle exercises referred to as Kegel exercises. It strengthens pelvic floor
muscles in women and can reduce episodes of incontinence. The client can identify
perineal muscles by stopping urination midstream or by tightening the anal sphincter
as if to hold a bowel movement.
30. c- Skin that is continually moist becomes macerated (softened). Urine that
accumulates on the skin is converted to ammonia which is very irritating on the skin.
To maintain skin integrity, the client’s perineal skin is washed with water, rinses it
thoroughly and dries it gently.
31. b- Anemia is a condition in which the blood is deficient in red blood cells or
hemoglobin. Hemoglobin binds directly and easily with oxygen, releasing it in the body
tissues. Thus, anemia interferes with oxygen delivery to the tissues, leading to fatigue
and activity intolerance.
32. c- Hypoxemia refers to reduced oxygen in the blood and is characterized by a low
partial pressure of oxygen in arterial blood or low hemoglobin saturation. Hypoxia is a
condition of insufficient oxygen anywhere in the body form the inspired gas to the
tissues. Cyanosis is a bluish discoloration of the skin, nailbed, and mucous membranes
due to reduced hemoglobin-oxygen saturation. Anemia is a condition in which blood is
deficient in red blood cells and hemoglobin.
33. c- An approximate measurement of the depth for insertion of the tubing or catheter is
the distance between the client’s nose and the earlobe, or about 13 cm (5 inches) for
an adult.
34. c- Without applying suction, insert the catheter into either naris and advance it along
the floor of nasal cavity to avoid trauma and nasal turbinates. Apply suction for 5 to
10 seconds te prevent decrease in oxygen supply.
35. b- Orthopnea is the inability to breathe except in an upright or standing position.
Dyspnea is a term used for difficult breathing. Tachypnea is a rapid respiratory rate.
Apnea is the cessation of breathing.
36. d- When taking blood pressure, the nurse pumps the cuff up to about 30 mmHg above
the point where the pulse is no longer felt, that is the point when the blood flow in the
artery is stopped. Then the pressure is released slowly (2 to 3 mmHg per sound).
37. d- Cigarette smoking is the primary cause of chronic airflow limitation or chronic
obstructive pulmonary disease. Nicotine increases the peripheral vascular resistance
and tissue oxygenation can be impaired. Asthma and bronchitis are types of COPD.
38. c- Health teachings about proper nutrition, regular physical exercises and foot care are
essential concepts to be taught to clients with diabetes mellitus. Prevention nutrition
is not included in the teaching plan.
39. b- Type I and II diabetes mellitus differ significantly from each other. Type I DM is
inherited as a heterogeneous, multigenic trait. It is characterized by active
autoimmunity which is directed against the beta cells of the pancreas, fasting
hyperglycemia occurs when 80 to 90% of the beta cell mass has been destroyed, and
the occurrence of ketosis. Type II DM is an adult-onset diabetes and clients are non-
insulin dependent. It is a reversible type and can be prevented.
40. c- Modifiable risk factors include physical activity, nutrition and smoking. These are
the factors that can be manipulated in order to prevent the occurrence of illness. Age,
gender, genetic predisposition and race are examples of non-modifiable factors.
41. d-The initial action of the nurse is to assess the condition of the victims in the accident
to determine the extent of injuries. Options a, b and c are not the immediate actions
to take.
42. b- The patient with compromised airway and breathing has a least stable condition
and should be given the highest priority to prevent detrimental effects to patient.
43. c- Hemorrhage is an emergency; the nurse should control and reduce bleeding of the
wound by applying pressure dressings to the area and monitor the client’s vital signs.
44. d-The application of pressure dressings on the bleeding site will promote hemostatsis.
Hemostasis is the cessation of bleeding which results from vasoconstriction of the
large blood vessels in the affected area.
45. c- The responsibilities of the nurse when the client is to be discharged include
providing instruction regarding wound care, emphasizing the importance of follow-up
care and proper documentation of treatment done and instructions given. Option c is
of least importance and not necessarily included during discharge.
46. c- An interview is a planned communication or conversation with a purpose, for
example, to get or give information, identify problems of mutual concern, teach,
provide support and therapy. Interview is a major part of the nursing assessment.
47. d-This is the most accurate way of documenting the client’s complaint. It is important
to remember that the information to be recorded is factual and complete.
48. d- People require essential nutrients in food for the growth and maintenance of all
body tissues and the normal functioning of the body processes. Discussing an
adequate food intake, which consist of balance essential nutrients: water,
carbohydrates, proteins, fats, vitamins and minerals, is important.
49. b- Maternal factors that contribute to a higher risk of low-birth weight babies include
poor nutrition, smoking cigarettes, use of alcohol and caffeine during pregnancy.
Nutritional needs are met when the mother eats a well-balanced diet containing
sufficient calories to meet both her needs and those of fetus.
50. d- Osteoporosis is a non-communicable disease which is associated with a decrease in
bone density, along with increased brittleness of bone which make a person prone to
serious fracture. Osteoporosis is not often considered a pregnant woman’s disease.
51. d-The four management functions are planning (describes how the intended outcome
is to be achieved or evaluated); organizing (determining responsibilities and establish
chain of command for authority); directing (assigning and communicating
expectations about the task to be completed); and coordinating (includes evaluating
the staff).
52. c- An autocratic leader makes decisions for the group. A democratic (participative,
consultative) leader encourages group discussion and decision-making. The laissez
faire (nondirective, permissive) leader recognizes the group’s needs for autonomy and
self-regulation (hands-off approach of the leader). The manager’s job is to accomplish
the work of the organization.
53. d-The head nurse is demonstrating authority, which is defined as the legitimate right
to direct the work of others, and always associated with responsibility and
accountability. Accountability is the ability to assume responsibility for one’s actions.
Responsibility is the obligation to complete a task. Delegation is the transference of
responsibility and authority for the performance of an activity to a competent
individual.
54. c- Irrigation of nasogastric tubes may not be delegated to non-nurse health worker
because this requires the knowledge and skills of a nurse. This procedure is very
invasive and the safety of the client is to be considered. Taking of vital signs, change
of IV infusions, and transfer from bed to chair are tasks that can be delegated to non-
nurse health members.
55. b- The nurse is demonstrating accountability (to assume responsibility for one’s
actions and to accept consequences of one’s behavior).
56. c- When taking blood pressure, the nurse pumps the cuff up to about 30 mmHg above
the point where the pulse is no longer felt; that is the point when the blood flow in the
arter7 is stopped. Using a stethoscope, the nurse identifies the phases of Korotkoff’s
sounds. Observing infection control is important. For comparison purposes, take the
BP on both arms.
57. d- Pulse oximeter is a non-invasive device that measures a client’s arterial blood
oxygen saturation by means of a sensor attached to the client’s fingers.
58. c- Blood pressure cuffs come in various sizes because the bladder must be the correct
width and length for the client’s ar. If the bladder is too narrow, the BP reading will be
erroneously elevated; if too wide, the reading will be erroneously low.
59. b- When taking the BP of a client who recently smoked or drank coffee, 20 to 30
minutes of rest/waiting time is indicated before the BP can be reliably assessed.
Nicotine and caffeine increase vasoconstriction of the arterioles, thus increasing the
BP reading.
60. c- Cover the sensor with a sheet or towel to block large amounts of light from external
sources (e.g., sunlight). Large amount of sunlight may be sensed by the photodetector
and alter oxygen saturation value.
61. d- Bioethics is an ethical principle that governs right conduct concerning life. Morality
is a doctrine or system denoting what is right and wrong in conduct, character or
attitude. Religion is an organized system of worship. Values are something of worth; a
belief held dearly by a person.
62. a- The Nurse’s Code of Ethics is a formal statement of a group’s ideals and values,
reflecting their moral judgments and serving as a standard for professional actions.
The purpose is to delineate the scope and area of nursing profession.
63. d- Nurses must possess professional accountability and responsibility. It means “being
answerable to oneself and others for one’s own action.”
64. c- A client does not have the prerogative to obtain information about another patient.
The nurse should ensure the confidentiality of all personal data/information of all
clients. Rights to consent, continuity of care and confidentiality are all included in
Patient’s Bill of Rights
65. d- Autonomy is a state of being independent and self-directed, without outside control,
to make one’s own decision. Fidelity is a moral principle that obligates the individual
to be faithful to agreement and responsibilities one has undertaken. Justice is
synonymous to fairness.
66. d- Quality assurance program is an ongoing, systematic process designed to evaluate
and promote excellence in the health care. In this program, the client’s record is
evaluated, direct observation, interview are utilized. Peer review can also be used, in
which, peers (nursing functioning in the same capacity) appraise the quality or
practice by other equally qualified nurse. The nursing interventions classification is not
use in quality assurance program.
67. b- The standards of nursing practice refer to the scope of nursing practice as defined
in RA 9173. It describes the responsibilities for which nurses are responsible.
68. b- A DNR order is generally written when the client or proxy has expressed the wish
for no resuscitation in the event of respiratory or cardiac arrest. This order must be
witnessed by two people. As a client advocate, it is important for the nurse to
facilitate family discussion about end-of-life concerns and decisions.
69. b- The blood should never be warmed or left at room temperature for 30 minutes or
more because the RBC cells deteriorate and lose their effectiveness. At room
temperature, lysis of RBCs releases potassium into the bloodstream, causing
hyperkalemia. As blood components warm, the risk of bacterial growth also increases.
70. a- In emergency cases, an order for restraints should be ensured and the doctor
should sign within 24 hours. Removing restraints every 2 to 4 hours and providing
range-of-motion exercises is an important consideration. Assessment of client’s
condition should be assessed every 4 hours for an adult, at least every 2 hours for
children ages 9 to 17, and once every hour for children under the age of 9.
71. d -Sodium intake should be maintained low (2,400 to 3,000 mg) each day. Instruct the
client to take 1 tsp of salt/day but no patis and toyo which are both high in sodium
content.
72. b- Condiments are used to enhance the flavor of food (ex. Pungent seasonings,MSG).
This contains a large amount of sodium and should not be used to replace table salt.
73. d- Cooking demonstration and meal planning will encourage the young mothers to
learn about proper nutrition. Demonstration technique is an effective strategy and
approach in giving nutrition education.
74. d- Cancer has a good prognosis if detected early and prompt intervention is executed.
75. c- Health education is based on the health needs of the people, also specific health
promotion goals must be set. Health education intends to prevent the acquisition of
illness and promotion of healthy lifestyle (e.g., smoking cessation).
76. c – total volume (in ml)/time to be infused (hour) = 2700 ml/ 18 hours = 150 ml/hr
77. c – Replacement fluid + volume of hurly infusion = 250 + 150 = 400 ml is the amount
of fluid the client should receive at 11 am.
78. b- Transdermal patch should not be applied to areas with cuts, burns, or abrasions or
on distal parts of extremities. The patch is applied to hairless, clean area of skin that is
not subject to excessive movement or wrinkling. All application should be changed
regularly to prevent local irritations.
79. c – Approach the eye from the side, then; instill the correct number of drops onto the
outer third of the lower conjunctival sac. Drops will harm the cornea if dipped directly
on it.
80. c – The reason for discarding the first bead of ointment before application is not to
expel more than the desired amount. The first bead is discarded because it is
considered contaminated. Hold the tube above the lower conjunctival sac, squeeze 2
cm of ointment into the lower conjunctival sac from the inner canthus outward.
Instruct the client to close the eyelids but not to squeeze them shut.
81. b- The nurse is demonstrating an efficient management of her subordinates. Proper
assignment and/or delegation of task to the staff nurses is a function of a nurse
supervisor. Mobilizing the members to ensure that each individual has a particular
responsibility to assume exemplifies that the nurse supervisor is utilizing human
resources effectively.
82. b- It is important to remember that the nurse may delegate a task to an unlicensed
staff, however, the accountability for action or inaction of the nurse and unlicensed
staff remains with the nurse.
83. c – The nurse supervisor should discuss how the new nurse is adjusting to her new job.
This would allow the new nurse to open up or share her feelings and/or concerns
towards her job.
84. c – Collective bargaining is the formalized decision-making process between
representatives of management (employer) and representatives of labor (employees)
to negotiate wages and conditions of employment. Strike is an organized work
stoppage by a group of employees to solve a dispute with management.
85. b- In-service education program is administered by an employer; it is designed to
upgrade the knowledge or skills of employees. Some in-services programs are
mandatory, such as cardiopulmonary resuscitation and fire safety programs.
Continuing education refers to formalized experiences designed to enlarge the
knowledge or skills of practitioners
86. b- Telehealth program projects use communication and information technology (e.g.,
television, video conferences) to provide health information and health care services
to people in remote areas.
87. d- Wellness center provides services such as health promotion, health maintenance,
education, counseling and screening. Community outreach centers provide services
similar to those traditionally provided by large public health clinics and focused on
narrower population.
88. d-When a client state readiness to improve her nutritional status this means that the
client is determined to decide the goals and interventions required to meet her goals.
The nurse will act as an advocate, that is, the nurse will support and reinforce the
client’s positive behaviors. Assuming responsibility for one’s health will promote self-
empowerment.
89. c- Tertiary prevention focuses on restoration and rehabilitation with the goal of
returning the individual to an optimal level of functioning. Primary prevention focuses
on health promotion and protection against specific health problems. Secondary
prevention focuses on early detection or identification of health problems and prompt
intervention to alleviate health problems.
90. b- Secondary prevention focuses on early detection or identification of health
problems and promptintervention to alleviate health problems. Tertiary prevention
focuses on restoration and rehabilitation with the goal of returning the individual to an
optimal level of functioning. Primary prevention focuses on health promotion and
protection against specific health problems.
91. b- The nurse should introduce himself and state the purpose in being with the client.
This would create an atmosphere that facilitates trust. Trust is an essential first step in
a therapeutic relationship.
92. c- This statement would encourage verbalization of feelings, perceptions and fears.
Open expression of feelings facilitates identification of specific emotions and fears.
93. c- It is important to identify the client’s level anxiety to determine the client’s
decision-making ability and how much information he can understand.
94. c- Cold compress lowers the temperature of the skin and underlying tissues and
causes vasoconstriction. Vasoconstriction reduces blood flow to affected area, thus
decreases swelling or inflammation. It also has local anesthetic effect. Heat
application causes vasodilation.
95. c- Hot compress causes vasodilation and increases blood flow to the affected area,
bringing oxygen, nutrients, antibodies and leukocytes for better and faster healing.
96. b- Full disclosure is a basic right, which means that deceptions, either by withholding
information about a client’s participation in a study or by giving the client false or
misleading information about what participating in the study will involve must not
occur.
97. b- This type of research activity intends to identify clinical problem. It entails
information/data regarding the factors that cause postoperative infections. This
research activity aids to problem identification and resolution.
98. b- Quantitative research progresses through systematic, logical steps according to a
specific plan to collect numerical information, often under conditions of considerable
control that is analyzed using statistical procedure. Options a, c, and d are examples
of qualitative research.
99. b- Feasibility pertains to the availability of time as well as the material and human
resources needed to investigate a research problem or question. It involves the use of
space, money, equipment and people.
100.d- Measures of variability indicate the degree of dispersion or spread of the data.
These include the range, variance, and standard deviation. Measures of central
tendency describe the center of a distribution of data, denoting where most of the
subjects lie. These include the mean, median and mode.