NURSING PRACTICE 1 Situation 1 - Mr.
Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3mg subcutaneously a. b. c. d. 1. The indication for epinephrine injection for Mrs. Simon is to: Reduce anaphylaxis Relieve hypersensitivity to allergen Relieve respiratory distress due to bronchial spasm Restore client's cardiac rhythm
CORRECT ANSWER: C RATIONALE: Asthma is a chronic inflammatory disorder of the airways resulting in reversible bronchoconstriction and air hunger in response to triggers from a variety of sources. When exposed to a trigger, the hyperactivity of the mediumsized bronchi causes the release of leukotrienes, histamine and other substances from the mast cells of the lung; these agents intensify the inflammatory process and cause bronchospasm. When inhaled in small doses, epinephrine causes short-term relief from the symptoms by widening the bronchial tubes allowing air to pass through. Once again epinephrine is not the best cure, but a temporary relief when an asthma inhaler is not present. OPTIONS A & D are incorrect OPTION B: Epinephrine does have a direct effect to relieve hypersensitivity to allergen SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pathophysiology.pp.4-5; http://www.udel.edu/chem/C465/senior/fall00/Performance1/epinephrine.htm.html 2. When preparing the epinephrine injection from an ampule, the nurse initially: a. Taps the ampule at the top to allow fluid to flow to the base of the ampule b. Checks expiration date of the medication ampule c. Removes needle cap of syringe and pulls plunger to expel air d. Breaks the neck of the ampule with a gauze wrapped around it CORRECT ANSWER: B RATIONALE: In preparing medications in ampule or any form of medications, always check first the expiration date and discard outdated medication. Check the label on the ampule carefully to make sure that the correct medication is being prepared. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 816 3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient. It is best for the nurse to: a. Inject needle at a 15 degree angle over the stretched skin of the client b. Pinch skin at the injection site and use airlock technique c. Pull skin of patient down to administer the drug in a Z track d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle CORRECT ANSWER: D RATIONALE:To determine the angle of insertion , a general rule to follow relates to the amount of tissue that can be grasped at the site. A 45-degree angle is used when 1 inch of tissue can be grasped at the site; a 90-degree angle is used when 2 inches of tissue can be grasped.
OPTION A: Skin Test OPTION C: IM SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 822 4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: Syringe 3ml and needle gauge 21 to 23 Tuberculin syringe 1 ml with needle gauge 26 or 27 Syringe 2ml and needle gauge 22 Syringe l-3ml and needle gauge 25 to 27 CORRECT ANSWER: D RATIONALE: The type of syringe used for subcutaneous injections depends on the medication given. Generally a 2-ml syringe is used for most SC injections. However, if insulin is being administered, an insulin syringe is used; and if heparin is being administered, a tuberculin syringe or prefilled cartridge may be used. Needle sizes and lengths are selected based on the clients body mass,the intended angle of insertion and the planned site. Generally a #25-gauge, 5/8-inch needle is used for adults. OPTIONS A, B & C are incorrect SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 822 5. The rationale for giving medications through the subcutaneous route is; There are many alternative sites for subcutaneous injection Absorption time of the medicine is slower There are less pain receptors in this area The medication can be injected while the client is in any position CORRECT ANSWER: B RATIONALE: Subcutaneous injections are given because there is little blood flow to fatty tissue and the injected medication is generally absorbed more slowly, sometimes over 24 hours. Some medications injected subcutaneously are growth hormone, insulin, epinephrine and other substances. OPTIONS A, C & D are all secondary reasons. SOURCE: http://www.cc.nih.gov/ccc/patient_education/pepubs/subq.pdf Situation 2 - The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials. 6. Martha wants to do a study on the topic. "Effects of massage and meditation on stress and pain." The type of research that best suits this topic is: Applied research Qualitative research Basic research Quantitative research CORRECT ANSWER: B RATIONALE: Qualitative research is the investigation of phenomena, typically in an in depth and holistic fashion, through the collection of rich narrative materials using a flexible design. Qualitative research relies on reasons behind various aspects of behavior. Simply put, it investigates the why and how of decision making, not just what, where, and when. Hence, the need is for smaller but focused samples rather than large random samples, which qualitative research categorizes data into patterns as the primary basis for organizing and reporting results. Qualitative researchers typically rely on four methods for gathering information: (1) participation in the setting, (2) direct observation, (3) in depth interviews, and (4) analysis of documents and
materials OPTION A: Applied research focuses on finding solutions to existing problems. For example, a study to determine the effectiveness of a nursing intervention to ease grieving would be applied reaserch. OPTION C: Basic research is undertaken to extend the base of knowledge in a discipline, or to formulate or refine theory. OPTION D: Quantitative research is the investigation of phenomena that lend themselves to precise measurement and quantification, often involving rigorous and controlled design. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp 18, 729; http://en.wikipedia.org/wiki/Qualitative_research 7. The type of research design that does not manipulate independent variable is: Experimental design Quasi-experimental design Non-experimental design Quantitative design CORRECT ANSWER: C RATIONALE: Non-experimental research- studies in which the researcher collects data without introducing an intervention. OPTION A: In experiment, the researcher controls the independent variable and randomly assigns subjects to different conditions. OPTION B: Quasi-experiment is an intervention study in which subjects are not randomly assigned to treatment conditions, but the researcher exercises certain controls to enhance the study’s internal validity. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp. 718,725,729 8. This research topic has the potential to contribute to nursing because it seeks to: Include new modalities of care Resolve a clinical problem Clarify an ambiguous modality of care Enhance client care CORRECT ANSWER: D Rationale: Nursing research is systematic inquiry designed to develop knowledge about issues of importance to the nursing profession, including nursing practice, education administration, and informatics. Research designed to generate knowledge and to improve the health and quality of life of nurse’s clients. Nurses increasingly are expected to adopt an evidenced-based practice, which is broadly defined as the use of best clinical evidence in making patient care decisions. OPTIONS A,B and C are also correct but the best is option D SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp. 3-4 9. Martha does review of related literature for the purpose of: Determine statistical treatment of data research Orientation to what is already known or unknown To identify if problem can be replicated Answering the research question CORRECT ANSWER: D RATIONALE: All of the choices are correct except D. Answer to the research question may be found after conducting the study. The following are purposes of a literature review: Identification of a research problem and development or refinement of research
questions or hypothesis Orientation to what is known and not known about an area of inquiry, to ascertain what research can best make a contribution to the existing base of evidence Determination of any gaps or inconsistencies in abody of research Determination of a need to replicate a prior study in a different setting or with a different study population Identification or development of new or reined clinical interventions to test through empirical research Identification of relevant theoretical or conceptual frameworks for a research problem Identification of suitable designs and data collection methods for a study For those developing research proposals for finding, identification of experts in the fields who could be used as consultants Assistance in interpreting study findings and in developing implications and recommendations SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp. 5 10. Client's rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT: right of self-determination right to compensation right of privacy right not to be harmed CORRECT ANSWER: B RATIONALE: All are the client’s rights for being the subject in a research except option B. The following are the basic human rights of research subjects: Right to informed consent The right to refuse and/or withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be protected from harm SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp.110-111 Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive secretions in the airway, 11. Mario listens to Richard's bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be: Client lying on his back then flat on his abdomen on Trendelenburg position Client seated upright in bed or on a chair then leaning forward in sitting position Client lying flat on his back and then flat on his abdomen Client lying on his right then left side on Trendelenburg position CORRECT ANSWER: B RATIONALE: Postural Drainage involves a patient assuming various positions to facilitate the flow of secretions from various parts of the lung into the bronchi, trachea and throat so that they can be cleared and expelled from the lungs more
easily. The diagram below shows the correct positions to assume for draining different parts of the lung. OPTIONS A and C are inappropriate OPTION D will drain the lower lobes of the lung SOURCE: http://www.huff-n-puff.net/posturaldrainage.htm
12. When documenting outcome of Richard's treatment, Mario should include the following in his recording EXCEPT: Color, amount and consistent of sputum Character of breath sounds and respiratory rate before and after procedure Amount of fluid intake of client before and after the procedure Significant changes in vital signs CORRECT ANSWER: C RATIONALE: The nurse needs to evaluate the client’s tolerance of postural drainage by assessing the stability of the clients vital signs, particularly the pulse and respiratory rates and by noting signs of intolerance, such as pallor, diaphoresis, dyspnea and fatigue.Following Postural drainage, the nurse should auscultates the client’s lungs, compare the findings to the baseline data, and document the amount, color, and character of expectorated secretions. OPTION C is not part of the documentation. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305 13. When assessing Richard for chest percussion or chest vibration and postural drainage Mario would focus on the following EXCEPT: Amount of food and fluid taken during the last meal before treatment Respiratory rate, breath sounds and location of congestion Teaching the client's relatives to perform 'the procedure Doctor's order regarding position restriction and client's tolerance for lying flat CORRECT ANSWER: C RATIONALE: Option C, though is part of nursing interventions but it is not the focus during this time. OPTION A is important to prevent vomiting and aspiration OPTION B will give the nurse baseline data OPTION D is important because certain position is contraindicated to the client that may further lead to dyspnea SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305
14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration when doing the procedure? Respiratory rate of 16 to 20 per minute Client can tolerate sitting and lying position Client has no signs of infection Time of last food and fluid intake of the client CORRECT ANSWER:D RATIONALE: Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion. The best times include before breakfast, before lunch, in the late afternoon and before bedtime. It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce vomiting. OPTION A has no special consideration since it is normal OPTIONS B & C don’t have any special considerations SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305 15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedure is; Percussion uses only one hand white vibration uses both hands Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle In both percussion and vibration the hands are on top of each other and hand action is in tune with client's breath rhythm Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air CORRECT ANSWER: A RATIONALE: Percussion sometimes called clapping is forceful striking of the skin with cupped hands. Vibration is a series of vigorous quiverings produced by hands that are placed flat against the client’s chest wall. Option A is true to both percussion and vibration. OPTION B is not the correct way OPTION C: percussion can be done with one hand OPTION D: percussion is not slapping SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.1303,1305 Situation 4 - A 61 year old man, Mr. Regalado, is admitted to the private ward for observation; after complaints of severe chest pain. You are assigned to take care of the client. 16. When doing an initial assessment, the best way for you to identify the client's priority problem is to: Interview the client for chief complaints and other symptoms Talk to the relatives to gather data about history of illness Do auscultation to check for chest congestion Do a physical examination white asking the client relevant questions CORRECT ANSWER: A RATIONALE: An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluating change, teach, provide support or provide counseling or
therapy. Initially during an assessment, the nurse first asks the complaints of the client and the associated symptoms so that initial intervention can be done. OPTION B: the client is the primary source of data OPTIONS C and D: may follow after SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.265 17. Upon establishing Mr. Regalado's nursing needs, the next nursing approach would be to: Introduce the client to the ward staff to put the client and family at ease Give client and relatives a brief tour of the physical set up the unit Take his vital signs for a baseline assessment Establish priority needs and implement appropriate interventions CORRECT ANSWER: C RATIONALE: Assessment is always done first before anything else. OPTION A and B are interventions OPTION D is diagnosing, planning and interventions 18. Mr. Regalado says he has "trouble going to sleep". In order to plan your nursing intervention you will. Observe his sleeping patterns in the next few days Ask him what he means by this statement Check his physical environment to decrease noise level Take his blood pressure before sleeping and upon waking up CORRECT ANSWER: B RATIONALE: It is another question for prioritization. Clarifying what the patient mean of “trouble going to sleep” enable the nurse to plan for the appropriate intervention. OPTION A is inappropriate, may require some time before the intervention OPTIONS C is judgmental that the noise is the cause of trouble in sleeping OPTION D is inappropriate without further assessment 19. Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following intervention would be the most appropriate immediate nursing approach. Moisturize lower extremities to prevent skin irritation Measure fluid intake and output to decrease edema Elevate lower extremities for postural drainage Provide the client a list of food low in sodium CORRECT ANSWER: A RATIONALE: All of the options are interventions for edema but option A is the immediate intervention. SOURCE: Black and Hawks. Medical Surgical Nursing.Vol. 1.7th Edition.pp. 217-218 20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: Teaching the factors that may trigger chest pain Giving instructions about his medication regimen Telling the patient to see the doctor for the final instruction Proper recording of pertinent data CORRECT ANSWER: C RATIONALE: Nurse preparing to send clients home needs to assess the following parameters in their clients: personal and health data, abilities to perform the
activities of daily living (ADLs), any physical, cognitive or other functional limitations, caregiver’s responses and abilities, adequacy of financial resources, community supports, hazards or barriers that the home environment presents and need for health care assistance in the home. Essential information before discharge includes information about medications, dietary, and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments an telephone numbers, and where supplies can be obtained. OPTION C is inappropriate. The nurse is giving the patient discharge instruction before leaving the hospital. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 114 Situation 5 - Accurate computation prior to drug administration is a basic skill all nurses must have. 21. Rudolf is diagnosed with amoebiasis and is to receive metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will receive per oral administration? 1,000 mg tid 500 mg tid 1,500 mg tid 250 mg tid CORRECT ANSWER: B RATIONALE: 1gram=1,000 milligram 1.5 gm x 1,000 mg = 1,500 mg 1,500 /3doses= 500 per oral administration 22. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. Which of the following should Nurse Paulo prepare for each oral dose? .5 ml 1.25 ml 2.5 ml 1 ml CORRECT ANSWER: A RATIONALE: Q= Drug prescribed/ drug available or stock = 62.5 mg/125mg/ml = 0.5 ml 23. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse? Report to the physician the effects of the medication on urination Take the medication early in the morning Take a full glass of water with the medication Measure frequency of urination in 24 hours. CORRECT ANSWER: B RATIONALE: furosemide (Lasix) is a diuretic that will increase urination so it is important to instruct patient to take the drug early in the morning to prevent problems in sleep because when taken at night, it will produced urinary frequency. OPTION A: Effects on urination is normal since it is a diuretics OPTION C: is not that important OPTION D: measuring the total amount of output is more important than the
frequency Situation 6 - Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage. 24. Instruction on health promotion regarding urinary elimination is important. Which would you include? Hold urine, as long as she can before emptying the bladder to strengthen her sphincters muscles If burning sensation is experienced while voiding, drink pineapple-juice After urination, wipe from anal area up towards the pubis Tell client to empty the bladder at each voiding CORRECT ANSWER: D RATIONALE: Promoting Urinary Elimination Instruct the client to respond to urge to void as soon as possible; avoid voluntary urine retention Teach the client to empty the bladder completely at each voiding Emphasize the importance of drinking 9-10 glasses of water daily Teach female clients about Kegel’s exercises to strengthen perineal muscles Etc. OPTION A is incorrect OPTION B might not always be correct, pineapple juice increase the acidity of urine but burning sensation may be an indication already of an existing disease. OPTION C: wiping should be from front to back 25. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation? inhibition of the parasympathetic reflex weakness of sphincter muscles of the anus loss of tone of the smooth muscles of the colon decreased ability to absorb fluids in the lower intestines CORRECT ANSWER: C RATIONALE: If the feces are very hard or if there is great difficulty in passing it out, then it is constipation. Causes of constipation Peristalsis of the intestine in the elderly is usually weakened, hence they are more prone to constipation. Aging may also affect bowel regularity because a slower metabolism results in less intestinal activity and muscle tone. Inadequate water or lack of fibre in food, leading to hard faeces. Psychological factors, e.g. using bedpan or commode chair without privacy, a dirty toilet, depression, etc. Drugs such as morphine group pain killers, certain diuretics, calcium tablets. Diseases, e.g. diabetic mellitus, hypothyroidism. SOURCE:http://healthlink.mcw.edu/article/930592170.html;http://www.info.gov.hk/eld erly/english/healthinfo/healthproblems/constipation.htm 26. The nurse understands that one of these factors contributes to constipation: excessive exercise high fiber diet no regular time for defecation daily prolonged use of laxatives CORRECT ANSWER: D Rationale: Laxatives contain chemicals that help increase stool motility, bulk,
and frequency -- thus relieving temporary constipation. But when misused or overused, they can cause problems, including chronic constipation! A healthy diet filled with fresh fruits, vegetables, and whole-grain products; regular exercise; and drinking at least eight cups of water daily can help prevent constipation in most people. Still, 85% of doctor visits for constipation result in a prescription for a laxative. So it's important to understand how laxatives work and how to use them safely. OPTION A&B will not cause constipation OPTION C: Some people think they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or three times a week, depending on the person. SOURCE: http://www.webmd.com/digestive-disorders/laxatives-for-constipation-usingthem-safely?src=RSS_PUBLIC 27. Mrs. Seva talks about her being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate .instruction would be to: tell client to drink less fluids to avoid accidents instruct client to start wearing thin adult diapers ask the client to bring change of underwear "just in case" teach client pelvic exercise to strengthen perineal muscles CORRECT ANSWER: D RATIONALE: It is important to remember that urinary incontinence is not part of normal aging and often treatable. Independent nursing interventions for clients with urinary incontinence include (a)a behavior-oriented continence training program that may consist of bladder training, habit training, prompted voiding, pelvic muscle exercises and positive reinforcement; (b) meticulous skin care and (c) for males, application of an external drainage device (condom-type catheter device). Pelvic muscle exercises (also known as Kegel exercises) work the muscles that you use to stop urinating. Making these muscles stronger helps you hold urine in your bladder longer. These exercises are easy to do. They can lessen or get rid of stress and urge incontinence. Kegel Exercises The muscles you want to exercise are your pelvic floor muscles. These are the ones you use to stop the flow of urine or to keep from passing gas. Often doctors suggest that you squeeze and hold these muscles for a certain count, and then relax them. Then you repeat this a number of times. You will probably do this several times a day. Your doctor will give you exact directions. OPTIONS A,B and C are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1270; http://www.niapublications.org/agepages/urinary.asp 28. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by Using thick diapers to absorb urine well Drying the skin with baby powder to prevent or mask the smell of ammonia Thorough washing, rinsing and drying of skin area that get wet with urine Making sure that linen are smooth and dry at all times CORRECT ANSWER: C RATIONALE: Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to the
skin. Because both skin irritation and maceration predispose the client to skin breakdown and ulceration, the incontinent person requires meticulous skin care. To maintain skin integrity, the nurse washes the client’s perineal area with soap and water after episodes of incontinence, rinses it thoroughly, dries it gently and thoroughly and provides clean, dry clothing or bed linen. If the skin is irritated, the nurse applies barrier creams such as zinc oxide ointment to protect it from contact with urine. If it is necessary to pad the client’s clothes for protection, the nurse should use products that absorb wetness and leave a dry surface in contact with the skin. OPTION A and B: Use of diapers and other containment devices may prevent the bedding and clothing from getting soiled, however they tend to keep the urine or stool in constant contact with the skin. Within a short period of time, the skin can become damaged. Special care must be taken to prevent skin breakdown by keeping the skin clean and dry. OPTION D is also correct but the best is option C SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1271; http://www.healthcentral.com/ency/408/003976.html Situation 7 - Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse's knowledge and ability to identify and immediately intervene to meet these needs is important to save lives. 29. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues? Carol with a tumor in the brain Theresa with anemia Sonny Boy with a fracture in the femur Brigette with diarrhea CORRECT ANSWER: B RATIONALE: Anemia is a condition characterized by abnormally low levels of healthy red blood cells or hemoglobin (the component of red blood cells that delivers oxygen to tissues throughout the body). The tissues of the human body need a regular supply of oxygen to stay healthy. Red blood cells, which contain hemoglobin that allows them to deliver oxygen throughout the body, live for only about 120 days. When they die, the iron they contain is returned to the bone marrow and used to create new red blood cells. Anemia develops when heavy bleeding causes significant iron loss or when something happens to slow down the production of red blood cells or to increase the rate at which they are destroyed. OPTIONS A, C and D has no direct effect in the oxygenation of tissues. SOURCE: http://www.answers.com/topic/anemia?cat=health 30. You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood. This condition is called: Cyanosis Hypoxia Hypoxemia Anemia CORRECT ANSWER: C RATIONALE: Hypoxemia is an abnormal deficiency in the concentration of oxygen in arterial blood (Mosby's Medical Dictionary). OPTION A: Cyanosis-a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood OPTION B: Hypoxia -a condition in which there is a decrease in the oxygen supply to a tissue.
OPTION D: Anemia is having less than the normal number of red blood cells or less hemoglobin than normal in the blood. 31. You will do nasopharyngeal suctioning to Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be: tip of the nose to the base of the neck the distance from the tip of the nose to the middle of the cheek the distance from the tip of the nose to the tip of the ear lobe eight to ten inches CORRECT ANSWER: C RATIONALE: Oropharyngeal or nasopharyngeal suctioning removes secretions from the upper respiratory tract. Make an appropriate measure of the depth of the catheter by measuring the distance between the tip of the client’s nose and the earlobe, or about 13 cm (5 inches) for an adult. OPTIONS A, B and D are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1318, 1320 32. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by: Applying suction for at least 20-30 seconds each time to ensure that all secretions are removed Using gloves to prevent introduction of pathogens to the respiratory system Applying no suction while inserting the catheter Rotating catheter as it is inserted with gentle suction CORRECT ANSWER: C RATIONALE: For nasopharyngeal suctioning, without applying the suction, insert the catheter premeasured or recommended distance into either nares and advance it along the floor of the nasal cavity. This avoids the nasal turbinates. Never force the catheter against an obstruction. If one nostril is obstructed, try another. OPTION A: Suction is applied for 5 to 10 seconds while slowly withdrawing the catheter. A suction attempt should last only 10 to 15 seconds. OPTION B is true to prevent infection but not avoiding trauma OPTION D: The catheter is rotated during suction not during the insertion of catheter and no suction is applied during the insertion of the catheter. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1320 33. Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively and comfortably. The nurse documents this condition as: Apnea Orthopnea Dyspnea Tachypnea CORRECT ANSWER: B RATIONALE: Orthopnea: The inability to breathe easily unless one is sitting up straight or standing erect. OPTION A: Apnea is the temporary cessation of breathing OPTION C: Dyspnea: Difficult or labored breathing; shortness of breath. OPTION D: Abnormally fast breathing. A respiratory rate that is too rapid. SOURCE: http://www.medterms.com/script/main/art.asp?articlekey=5702 Situation 8 - You are assigned to screen for hypertension: Your task is to take blood pressure readings and you are informed about avoiding the common mistakes in BP taking that lead to 'false or inaccurate blood pressure readings.
34. When taking blood pressure reading the cuff should be: deflated fully then immediately start second reading for same client deflated quickly after inflating up to 180 mmHg large enough to wrap around upper arm of the adult client 1 cm above brachial artery inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or brachial artery CORRECT ANSWER: D RATIONALE: Pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared. OPTION A: Wait 1 to 2 minutes before making further measurements. A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur. OPTION C: Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center of the bladder directly over the artery. The bladder inside the cuff must be directly over the artery to be compressed if the reading is to be accurate. For an adult, place the lower border of the cuff approximately 2.5 cm or 1 inch above the antecubital space. OPTION D is inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 515-516 35. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is a preventable disease. The primary cause of COPD is: tobacco hack bronchitis asthma cigarette smoking CORRECT ANSWER: D RATIONALE: COPD is a chronic lung disease. It has its own symptoms. The most common cause of COPD is known. And it's preventable. Smoking is the primary cause of COPD. It is 10 times more likely that a smoker will get COPD than a nonsmoker. Exposure to secondhand tobacco Cigarette smoke causes COPD by irritating the airways and creating inflammation that narrows the airways, making it more difficult to breathe. Cigarette smoke also causes the cilia to stop working properly so mucus and trapped particles are not cleaned from the airways. As a result, chronic cough and excess mucus production develop, leading to chronic bronchitis. OPTION B: is one of the diseases in COPD OPTION A and C:incorrect SOURCE: http://www.clevelandclinic.org/health/healthinfo/docs/2400/2416.asp?index=8709 http://www.copdguide.com/copd-is-different.jsp 36. In your health education class for clients with diabetes you teach, them the areas for control Diabetes which include all EXCEPT: regular physical activity thorough knowledge of foot care prevention of infection proper nutrition CORRECT ANSWER: B RATIONALE: Option D: In order to maintain a constant blood sugar level, diabetics
should ideally eat approximately the same amount of food per day, with a set number of calories at around the same time of day so that blood sugar levels don’t fluctuate too much. In addition, healthy snacks should be enjoyed to stop the blood glucose levels from dropping too much in between meals. Meals should never be skipped and the day’s food should contain a mixture of whole grains, fruits, lean meat or meat substitutes i.e. corn, vegetables and low fat dairy products. OPTION A: In conjunction with a healthy low fat diet, moderate exercise should be taken at least five times a week for around 30 minutes each session. How a diabetic person chooses to exercise will depend to some extent on their initial level of fitness i.e. obese people will not go jogging or cycling for miles at a time, and any exercise routine should only be performed after consulting a doctor. As an individual starts to lose weight then the level of physical activity can be increased accordingly but overdoing it to begin will undoubtedly lead to even bigger problems. OPTION C: Infection may result to hyperglycemia because the body requires more glucose for energy. Thus preventing infection also control diabetes OPTION B: A knowledge on foot care prevents complication of diabetic foot but does not control diabetes itself. SOURCE: http://www.diabeticlive.com/articles/17/1/Controlling-Diabetes-With-DietAnd-Exercise/Page1.html 37. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which of the following is true? both types of diabetes mellitus clients are all prone to develop ketosis Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology Type I (IDDM) is characterized by fasting hyperglycemia Type II (IDDM) is characterized by abnormal immune response CORRECT ANSWER: B RATIONALE: While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age, we are seeing an alarming number patients with type 2 diabetes who are barely in their teen years. In fact, for the first time in the history of humans, type 2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor eating habits, higher body weight, and lack of exercise.Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival. In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against and cause damage to patients' own body tissues. In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood. OPTION A: ketoacidosis -- mostly in people with type 1 diabetes -- and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) in people with type 2 diabetes or in people at risk for type 2 diabetes. OPTION C:There is no such thing as fasting hyperglycemia OPTION D: Type I is characterized by abnormal immune response SOURCE: http://www.medicinenet.com/diabetes_mellitus/page3.htm 38. Lifestyle-related diseases in general share common risk factors. These are
the following except physical activity smoking genetics nutrition CORRECT ANSWER: C RATIONALE: A way of life or style of living that reflects the attitudes and values of a person or group. Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Categories of lifestyle generally assessed are physical activity, nutritional practices, stress management and such habits as smoking, alcohol consumption and drug use. OPTION C genetics is the scientific study of heredity. Genetics pertains to humans and all other organisms. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 128 Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of the accident. 39. Her priority nursing action would be to: Assess damage to property Assist in the police investigation since she is a witness Report the incident immediately to the local police authorities Assess the extent of injuries incurred by the victims, of the accident CORRECT ANSWER: D RATIONALE: The first priority whenever an accident occurs is to deal with the emergency and ensure that any injuries or illnesses receive prompt medical attention. SOURCE: http://web.princeton.edu/sites/ehs/healthsafetyguide/A2.htm 40. Priority attention should be given to which of these clients? Linda who shows severe anxiety due to trauma of the accident Ryan who has chest injury, is pale and with difficulty of breathing Noel who has lacerations on the arms with mild-bleeding Andy whose left ankle swelled and has some abrasions CORRECT ANSWER: B RATIONALE: Respiratory problems and problem with the oxygenation should always be the priority. OPTION A is least priority because it is a psychological need OPTION C is the second OPTION D is the third 41. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms, while assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to: Apply antiseptic to prevent infection Clean the wound vigorously of contaminants Control and reduce bleeding of the wound Bandage the wound and elevate the arm CORRECT ANSWER: D RATIONALE: Bleeding from any external wound sites on the victim's body should be controlled to prevent the victim from going into shock which could lead to death if not treated immediately.
Elevation - Keeping the wound above the level of the heart will decrease the pressure at the point of injury, and will reduce the bleeding. Direct Pressure - Placing pressure on the wound will constrict the blood vessels manually. After applying pressure for sometime, you can make a pressure bandage around the injury site. The key is to not make this too tight to cut all circulation because this could have direct consequences later on. The bandage should be tight enough to maintain pressure on the wound but not too tight to impede any blood flow. If the skin turns purple-blue or if there is no pulse present at the major pressure pints then the pressure bandage is on too tight. OPTION A does not address the immediate need of the patient OPTION B is incorrect because it may induce more bleeding OPTION C is correct but option D is more specific SOURCE: http://en.wikipedia.org/wiki/Emergency_bleeding_control 42. The nurse applies pressure dressing on the bleeding site. This intervention is done to: Reduce the need to change dressing frequently Allow the pus to surface faster Protect the wound from micro organisms in the air Promote hemostasis CORRECT ANSWER: D RATIONALE: Hemostasis is the stoppage of bleeding or hemorrhage. Also, the stoppage of blood flow through a blood vessel or organ of the body Pressure dressing is a nonadherent bandage applied over the incision that is covered by an absorbent layer and a stretchable adhesive. This application is intended to compress dead space and prevent hematoma and seroma formation. SOURCE: http://www.woundsresearch.com/Pressure-dressing 43. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities when the client is to be discharged include the following EXCEPT: Encouraging the client to go to the, outpatient clinic for follow up care Accurate recording, of treatment done and instructions given to client Instructing the client to see you after discharge for further assistance Providing instructions regarding wound care CORRECT ANSWER: C RATIONALE: Nurse preparing to send clients home needs to assess the following parameters in their clients: personal and health data, abilities to perform the activities of daily living (ADLs), any physical, cognitive or other functional limitations, caregiver’s responses and abilities, adequacy of financial resources, community supports, hazards or barriers that the home environment presents and need for health care assistance in the home. Essential information before discharge includes information about medications, dietary, and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments an telephone numbers, and where supplies can be obtained. OPTION C: The client does not have the direct appointment with the nurse after the discharge. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 114 Situation 10 - While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor's appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an assessment. 44. The nurse purpose of your initial nursing interview is to: Record pertinent information in the client chart for health team to read Assist the client find solutions to her health concerns
Understand her lifestyle, health needs and possible problems to develop a plan of care Make nursing diagnoses for identified health problems CORRECT ANSWER: C RATIONALE: An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluating change, teach, provide support or provide counseling or therapy. Initially during an assessment, the nurse first ask the complaints of the client and the associated symptoms so that initial intervention can be done. It is an umbrella effect. Option C encompasses options A, B and D. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.265 45. While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain occurs about an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows: Claims to have abdominal pains after intake of coffee unrelieved by analgesics After drinking coffee, the client experienced severe abdominal pain Client complained of intermittent abdominal pain an hour after drinking coffee Client reported abdominal pain an hour after drinking black coffee for few weeks now CORRECT ANSWER: D RATIONALE: To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. Data are recorded in a factual manner and not interpreted by the nurse. OPTION D is more complete recording of the patient’s complaints. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.274 46. Geline tells you that she drinks black coffee frequently within the day to "have energy and be wide awake" and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks, in planning a healthy balanced diet with Geline, you will: Start her off with a cleansing diet to free her body of toxins then change to a vegetarian, diet and drink plenty of fluids Plan a high protein, diet; low carbohydrate diet for her considering her favorite food Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily high energy level Discuss with her the importance of eating a variety of food from the major food groups with plenty of fluids CORRECT ANSWER: D RATIONALE: Diet planning principles (ABCNMV) 1. Adequacy -Provides sufficient energy and nutrients 2. Balance - Consume a number of different foods in appropriate proportion to each other 3. kCalorie control -Energy balance 4. Nutrient density -Large amount of nutrients in a food with a small amount of calories
5. Moderation -In consuming foods that are not nutrient dense 6. Variety -Consume a variety of foods within and among the food groups OPTION A is inappropriate because the patient is already in vegetable diet OPTION B is limited only in protein and carbohydrates OPTION C is limited to carbohydrates only SOURCE: http://www.usm.edu/~nfs362/chap2.out.PDF 47. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not want to become fat that is why she limits her food intake. You warn or caution her about which of the following? Caffeine products affect the central nervous system and may cause the mother to have a "nervous breakdown" Malnutrition and its possible effects on growth and development problems in the unborn fetus Caffeine causes a stimulant effect on both the mother and the baby Studies show conclusively that caffeine causes mental retardation CORRECT ANSWER: B RATIONALE: Maternal malnutrition impairs pregnancy outcome, increases maternal mortality and retards early childhood development. 18 million low-birth weight babies are born to undernourished mothers each year. This is a prime cause of infant mortality in developing countries OPTION A, C and D are all limited to effects of caffeine SOURCE: http://www.iaea.org/Publications/Booklets/Malnutrition/four.html 48. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of non-communicable diseases that are influenced by her lifestyle these include of the following EXCEPT: Cardiovascular diseases Cancer Diabetes Mellitus Osteoporosis CORRECT ANSWER: D RATIONALE: Your cardiovascular system consists of your heart and all blood vessels throughout your body. Diseases ranging from aneurysms to valve disease are types of cardiovascular disease. You may be born with some types of cardiovascular disease (congenital) or acquire others later on, usually from a lifetime of unhealthy habits, such as smoking, which can damage your arteries and cause atherosclerosis Cigarette smoking causes 87 percent of lung cancer deaths (1). Lung cancer is the leading cause of cancer death in both men and women (3). Smoking is also responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder. In addition, it is a cause of kidney, pancreatic, cervical, and stomach cancers (2, 4), as well as acute myeloid leukemia (2). OPTION D:Osteoporosis occurs when an imbalance occurs between new bone formation and old bone resorption. The body may fail to form enough new bone, or too much old bone may be reabsorbed, or both. Two essential minerals for normal bone formation are calcium and phosphate. Throughout youth, the body uses these minerals to produce bones. If calcium intake is not sufficient or if the body does not absorb enough calcium from the diet, bone production and bone tissue may
suffer. SOURCE: http://www.emedicinehealth.com/osteoporosis/page2_em.htm; http://www.cancer.gov/cancertopics/factsheet/Tobacco/cancer http://www.mayoclinic.com/health/cardiovascular-disease/HB00032/UPDATEAPP=0 Situation 11 - Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management experience. 49. An example of a management function of a nurse is: Teaching patient do breathing and coughing exercises Preparing for a surprise party for a client Performing nursing procedures for clients Directing and evaluating the staff nurses CORRECT ANSWER: D RATIONALE: Management has a unique purpose and outcome that is needed to maintain a healthy organization. Management functions include planning, organizing, staffing, directing and controlling. According to Kleinman,the basic components of management functions include planning, organizing, delegating, problem solving, evaluating and enforcing policies and procedures. Other options are not correct SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing. Theory and applications. 5th Edition.pp. 39-41 50. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the decisions for everyone without consulting anybody. This type of leadership is: Laissez faire leadership Democratic leadership Autocratic leadership Managerial leadership CORRECT ANSWER: C RATIONALE: Autocratic Leadership Style This is often considered the classical approach. It is one in which the manager retains as much power and decision-making authority as possible. The manager does not consult employees, nor are they allowed to give any input. Employees are expected to obey orders without receiving any explanations. The motivation environment is produced by creating a structured set of rewards and punishments. OPTION A:The laissez-faire leadership style is also known as the “hands-off¨ style. It is one in which the manager provides little or no direction and gives employees as much freedom as possible. All authority or power is given to the employees and they must determine goals, make decisions, and resolve problems on their own. OPTION B:The democratic leadership style is also called the participative style as it encourages employees to be a part of the decision making. The democratic manager keeps his or her employees informed about everything that affects their work and shares decision making and problem solving responsibilities. This style requires the leader to be a coach who has the final say, but gathers information from staff members before making a decision OPTION D:A manager’s style of managing has been a continuing cause of concern to his manager's style is one of the major contributors to the performance and effectiveness of his unit. The desire to define how a manager should conduct himself while working with others has led to investigations into those variables that may affect levels of managerial performance. This article examines, in summary form, investigations by various management authorities on the subject of managerial styles. These investigations have been developed into three theories of
managerial style: trait, behavior, and situation. SOURCE: http://www.essortment.com/all/leadershipstyle_rrnq.htm http://www.airpower.maxwell.af.mil/airchronicles/aureview/1976/mar-apr/dean.html