Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 1 Latest updated Graded A+

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During a physical assessment, the nurse closes and door and provides drape to promote privacy. The nurse is performing her role as a/an: A. Advocate B. Communicator C. Change agent D. Caregiver... - ANSWER D. Caregiver The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the client. Identifying the need and problems of the client and communicating it to other members of the health team is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. During the nursing rounds Nurse Cathy is instructing the patient to avoid smoking to prevent the worsening of respiratory problems. The patient asked about the things that he can do when feelings of wanting to smoke arises. The nurse enumerates ways of dealing the situation. This is an example of a nurse's role as a/an: A. Advocate B. Clinician C. Change agent D. Caregiver - ANSWER C. Change agent As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. As an advocate the nurse intercedes or works on behalf of the client. As a clinician, the nurse would use technical expertise to administer nursing care. The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically. Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based on Benner's theory she is a/an: A. Novice B. Expert C. Competent D. Advanced beginner - ANSWER B. Expert The ability to perceive something without further evidence is the development of intuition and is seen in Expert nurses. A novice nurse is governed by rules and usually inflexible. Competent nurses are planning nursing care consciously. Advanced beginners demonstrate acceptable performance. Newborn screening is done to every newborn in the Philippines. This is an example of: A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Rehabilitation - ANSWER B. Secondary prevention Promotion of early detection and early treatment of the disease is under secondary prevention. Example, breast self exam, TB screening, genetic counseling. One of Nurse Cathy's co-workers is Annie who is flexible in any given situation. Annie is performing her duties well without supervision but still needs more experience and practice to develop a consciously planned nursing care. According to Patricia Benner's category in specialization in nursing, Annie is a/an: A. Novice B. Expert C. Competent D. Advanced beginner - ANSWER D. Advanced beginner A- Novice is governed by rules and usually inflexible. B- Expert nurses have intuitive grasp on the situation dealt. C- Competent nurses are planning nursing care consciously. D- Advanced beginners demonstrate acceptable performance. The clinical instructor is discussing about the Nursing Process. She mentioned that when a cluster of actual or high-risk diagnosis are present because of a certain situation it is called: A. Wellness nursing diagnosis B. Actual nursing diagnosis C. Syndrome nursing diagnosis D. Risk nursing diagnosis - ANSWER C. Syndrome nursing diagnosis Presence of both actual and high-risk diagnosis is called a syndrome nursing diagnosis. Wellness nursing diagnosis focuses on the clinical judgment on an individual from a specific to higher level of wellness. Actual diagnoses are clinical judgment of the nurse that is validated. A risk diagnosis is based on the clinical are based on clinical judgment that the client may develop vulnerability to the problem. The nurse in charge measures a patient's temperature at 101 degrees F. What is the equivalent centigrade temperature? A. 36.3 degrees C B. 37.95 degrees C C. 40.03 degrees C D. 38.01 degrees C - ANSWER B. 37.95 To convert °F to °C use this formula, ( °F - 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? A. That the patient verbalized, "My headache is gone." B. That the patient's barium enema performed 3 days ago was negative C. Patient's NGT was removed 2 hours ago D. Patient's family came for a visit this morning. - ANSWER C. Patient's NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patient's condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? A. Stop the infusion B. Call the attending physician C. Slow that infusion to 20 ml/hr D. Place a cold towel on the site - ANSWER A. Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? A. Oriented to date, time and place B. Clear breath sounds C. Capillary refill greater than 3 seconds and buccal cyanosis D. Hemoglobin of 13 g/dl - ANSWER C. Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data. What is the order of the nursing process? A. Assessing, diagnosing, implementing, evaluating, planning B. Diagnosing, assessing, planning, implementing, evaluating C. Assessing, diagnosing, planning, implementing, evaluating D. Planning, evaluating, diagnosing, assessing, implementing - ANSWER C. Assessing, diagnosing, planning, implementing, evaluating The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating. Which of the following is the most important purpose of planning care with a patient? A. Development of a standardized NCP. B. Expansion of the current taxonomy of nursing diagnosis C. Making of individualized patient care D. Incorporation of both nursing and medical diagnoses in patient care - ANSWER C. Making of individualized patient care To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? A. Use sterile gloves when obtaining urine B. Open the drainage bag and pour out the urine C. Disconnect the catheter from the tubing and get urine D. Aspirate urine from the tubing port using a sterile syringe - ANSWER D. Aspirate urine from the tubing port using a sterile syringe The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: A. Pulse rate greater than 100 beats per minute B. Blood pressure of 140/90 C. Respiratory rate greater than 20 breaths per minute D. Frequent bowel sounds - ANSWER C. Respiratory rate greater than 20 breaths per minute A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor - ANSWER B. Nurse and patient Although diagnosing is basically the nurse's responsibility, input from the patient is essential to formulate the correct nursing diagnosis. The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular - ANSWER A. Wheezes Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? A. Low blood pressure B. Warm, dry skin C. Decreased serum sodium levels D. Decreased urine output - ANSWER D. Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? A. 30 degrees B. 90 degrees C. 45 degrees D. 0 degree - ANSWER D. 0 degree The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings. Which of the following is inappropriate nursing action when administering NGT feeding? A. Place the feeding 20 inches above the point of insertion of NGT B. Introduce the feeding slowly C. Instill 60ml of water into the NGT after feeding D. Assist the patient in fowler's position - ANSWER A. Place the feeding 20 inches above the point of insertion of NGT The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting During application of medication into the ear, which of the following is inappropriate nursing action? A. In an adult, pull the pinna upward B. Instill the medication directly into the tympanic membrane C. Warm the medication at room or body temperature [Show More]

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