Professional Documents
Culture Documents
fUNDA Rationale 2007 Edited
fUNDA Rationale 2007 Edited
fUNDA Rationale 2007 Edited
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do not want an autopsy performed. Which of the following responses
to the family is most appropriate?
a. “it is required by federal law. Why don’t we talk about it, and
why don’t you tell me why you don’t want the autopsy done?
b. “the decision is made by the medical examiner.”
c. “I will contact the medical examiner regarding your request.”
d. “An autopsy is mandatory for any client who is DOA.”
Answer: C
Rationale: An autopsy is required by state law in certain
circumstances, including the sudden death of a client and a death
that occurs under suspicious circumstances. A client may have
provided oral or written instructions regarding an autopsy following
death. If an autopsy is not required by law, these oral or written
requests will be granted. If no oral or written instructions were
provided, state law determines who has the authority to consent for
an autopsy. Most often, the decision rests with the surviving relative
or next of kin. (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p
1044)
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6. A registered nurse (RN) is planning assignments for the clients on a
nursing unit. The RN needs to assign four clients and has a registered
nurse and two nursing assistants on a nursing team. Which of the
following clients would the nurse most appropriately assign to the
nursing assistants?
a. A client who requires a 24-hour urine collection
b. An elderly client requiring assistance with a bed bath and
frequent ambulation
c. A client on a mechanical ventilator who requires frequent
assessment and suctioning
d. A client with an abdominal wound requiring wound irrigations
and dressing changes every 3 hours
Answer: B
Rationale: When delegating nursing assignments, the nurse
needs to consider the skills and educational level of the nursing
staff. Collecting a 24-hour urine and frequent ambulation can
most appropriately be provided by the nursing assistant
considering the clients identified in each of the options. The
client on the mechanical ventilator requiring frequent
assessment and suctioning should most appropriately be cared
for by the registered nurse.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 476, 477)
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B- is a traditional role of nurse; formerly the nurse was the sole
prerogative of the physician
C- in the past and in the present the nurse needs to coordinate
with other health care team members
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(self), the social (others/external) and the physical (biochemical
reactions) (Source: FNP by Taylor, 3rded, p. 67)
D –refers to Maslow’s hierarchy of needs. Maslow’s hieararchy
of needs is an interdisciplinary theory that is useful for
designing priorities of care. The hierarchy of human needs
arranges the basic needs in five levels of priority. The most
basic or first level includes physiologic needs, such as air, water
and food. The second level includes safe and security needs,
which involves physical and psychological security. The 3rd level
contains love and belonging needs, including friendships and
sexual love. The 4th level encompasses esteem and self-esteem,
which involve self-confidence, usefulness, achievement and self-
worth. The final level is the need for self-actualization, the state
of fully achieving potential and having the ability to solve
problems and cope realistically with life’s situations.
The hierarchy of needs is a useful way for nurses to plan
individualized care for a client. One need may take priority over
another (such as restoration of an adequate airway before the
nurse educates the client in adjusting to an emotional conflict.
The nurse uses priorities to organize nursing diagnosis, develop
goals, and expected outcomes and select nursing intervention
(Source: FNP by Taylor 3rd ed, p. 92)
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b. health promotion behaviors help persons maintain or achieve a
high level of functioning
c. the effect of demographic variables on health promoting
behaviors is clearly established
d. health promotion behaviors will decrease occupational health
risks
Answer: B
Health promotion is any activity undertaken for the purpose of
achieving a higher level of health and well-being. It is directed
toward improving well-being and actualizing the health potential of
individuals, families, groups, and communities. Health promotion is
more than the avoidance or prevention of disease. (source: FNP by
Kozier, 5th ed., p. 259)
A, C, D are under letter B
A – the tertiary prevention is included is a health promotion to
restore the optimum level of functioning within the constraints of
the disability. And also to prevent further disability
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17. A pediatric client has been diagnosed with conjunctivitis. The
nurse is to administer eye drops four times a day (QID). The nurse
should administer the medication by gently dropping the medication
onto which of the following areas?
a. Sclera by the inner canthus.
b. Center of the cornea.
c. Lower conjunctival sac
d. Sclera by the outer canthus
Answer: C
Eye drops are placed in the lower conjunctival sac to prevent damage
to the cornea and to facilitate coating the eye with the medication. The
other options are incorrect.
(Source: Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall
Nursing Reviews and Rationales p337)
19. When assisting with a bone marrow biopsy, the nurse should take
which of the following actions?
a. Stand in front of the client and support the back of the neck and
knees.
b. Assist the client to a right side lying position after the procedure.
c. Observe for signs of dyspnea, pallor and coughing.
d. Assess for bleeding and hematoma formation for several days
after the procedure.
Answer: C
The client may experience pain when the marrow is aspirated. Monitor
and support the client by explaining the procedure. Help the client
assume a supine position (with one pillow if desired) for a biopsy of the
sternum or a prone position for a biopsy of either iliac crests. Observe
the client for pallor, diaphoresis, and faintness due to bleeding or pain.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 780)
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transmission. Sensory perception defects such as impaired affect pain
perception by the Central Nervous System.
(Source: Hogan REVIEWS AND RATIONALES p235)
21. A client is hospitalized for the first time. Which of the following
actions ensures the safety of the client?
a. Keep lights on all the time.
b. Keep side rails up at all times.
c. Keep all equipment out of view.
d. Keep unnecessary furniture out of the way.
Answer: D
Rationale: The environment has to be clutter free. Therefore,
unnecessary pieces of equipment or furniture have to be out of the
way. Lights on and side rails up are not mandatory at all times. It is
unnecessary to keep equipment out of view.(Source: Hogan REVIEWS
AND RATIONALES p204)
23. There was a large disaster in the community. Many family homes
were destroyed and many individuals were injured. The community
health nurse and home health nurse assume their roles. What is the
responsibility of a home health nurse?
a. assessing and treating individuals injured
b. providing a safe water supply
c. establishing communication and support system
d. monitoring for communicable diseases
Answer: C
Nurses committed to family centered care involve both the ailing
individual and the family in the nursing process. Through this
interaction with families nurse can give support and information.
Nurses make sure that not only the individual but also each family
member understands the disease, its management and the effect of
these factors on family functioning. The nurses also help families cope
with the realities of the illness and changes it may have brought about.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 196)
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Rationale: Evaporation is the loss of heat when water or sweat on the
person’s skin converted to a vapor.
A- Radiation is the transfer of heat from the person to cooler surfaces
and objects not in direct contact with the person. Environmental
factors: Cold outside building walls and windows.
B- Conduction is the transfer of heat when the person comes in direct
contact with cooler surface or objects. Environmental factors: cold
stethoscope, cold hands of caregiver
C- Convection is the transfer of heat when a flow of cold air passed
over the person’s skin. Environmental factors: drafts air-conditioning
duct
(source: pathophysiology – Bullock, p.120)
25. In noting the Ronald’s pulse, the nurse should that the pulse is
most perceptible at a site where:
a. venous valves rhythmically reflect pulsation
b. peripheral resistance is highest
c. the blood vessel is most easily distensible by the pressure of blood
flowd
d. an artery passes over a bony prominence
Answer: D
Rationale: The pulse is a wave of blood created by contraction of the
left ventricle wherein blood enters the arteries with each heart beat. It
can be taken over the bony prominences. Ex: in the temporal where
the temporal artery passes over the temporal bone of the head
A, B, C will give an incorrect readings
(source: FNP by Udan,yr. 2001, p. 81)
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Answer: A
Rationale: The decision should be made by the nurse in giving the
meds not by the client. Since she is known hypertensive, the nurse
should give the meds to control her BP even though her BP is within
normal range.
28. Before taking the patient’s BP, which of the ff. must the nurse do?
a. cleanse the patient’s antecubutal fossa with an alcohol sponge
b. note the patient’s physique and age
c. wipe the cuff and the valve with dry cloth
d. palpate the brachial pulse
Answer: B
Rationale: BP increases with age or older people have higher BP due
to decreased elasticity of blood vessels. You have to note first the
client’s age to determine on what normal range of BP the client will fall
into. Noting the client’s physique would be a factor that could affect
BP. BP generally is elevated among overweight and obese people.
A- it is not necessary to do this unless the antecubital fossa is dirty
C- It’s not necessary to do this
D – palpatation of brachial pulse is done during deflation of the BP,
which is commonly used technique to obtain BP measurement often
when a client is in shock. Wherein it’s difficult to hear BP with a
standard stethoscope (source: MS nursing 6th ed, J. Black, p. 2252)
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31. An adult who has failed to satisfactorily resolve the
developmental task of adolescence which is identity versus confusion
may show which behavior?
a. goes along with the crowd in all activities
b. asserts independence
c. has difficulty working as a member of a team
d. is unable to express personal desires
Answer: C
Rationale: Some behaviors indicating negative resolution to the
developmental task – identity versus confusion are failing to assume
responsibility for directing one’s own behavior, accepting the values of
others without question and failing to set goals in life.
Options a and b are behaviors indicating positive resolution to the
developmental task –identity vs. confusion. Option d is a negative
behavior if autonomy among toddlers has not been met.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 958)
32. A client received a severe burn in a house fire. On the second day
of hospitalization, the physician orders the client to receive albumin.
The nurse explains to the client that which of the following is the
rationale for albumin administration?
a. Improve the level of clotting factors and prevent bleeding.
b. Replace the lost red blood cells and reduce the anemia.
c. Provide proteins to increase the osmotic pressure in the blood.
d. Provide fluid resuscitation to prevent dehydration.
Answer: C
Rationale: Protein is responsible for a significant portion of the
osmotic pressure found in the blood vessels and maintains fluid within
the vessels. In burn injuries, protein is lost allowing fluid to escape into
the tissues. Albumin is used to replace the lost proteins and pull fluids
from the interstitial space back into the vascular system. It does not
contain clotting factors, red blood cells, nor is there enough fluid
volume to consider it as part of primary fluid resuscitation. Mary Ann
Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p337
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a. a method for processing the care of many patients
b. a method for diagnosing and treating human responses to actual or
potential health problems
c. a method for diagnosing health problems/diseases
d. a logical systematic problem-solving method for providing nursing
care
Answer: D
A- is more on implementation
B- pertains to nursing dx and implementation
C- pertains to nsg dx
A, B, C are all components of nursing process that must be all present
done in a systematic way
(source: FNP by Udan, yr 2001, p. 65-70)
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(source: FNP by Kozier, 5th ed., pp. 107-111)
38. Betina, a dyspneic ask the nurse if she can be bathe sitting on a
chair. The nurse response should be:
a. ”I’m sorry, I’m only allowed to bathe you in bed”
b. “Since you are more comfortable on the chair, I will be happy to
assist you there”
c. “My supervisor would be upset if she sees me bathing you on the
chair”
d. “This is against hospital policy and how I have been taught.”
Answer: B
Client may be bathed in different positions whether on the bed or in
the chair as long as the client is comfortable. Since the client is
dyspneic, she is more comfortable in a sitting position and it’s not
contraindicated to bathe her in the position.
A, C & D are nontherapeutic approach which will make the client
irritated that could increase her dyspnea further.
SITUATION: Mrs. Dela Pena, your adult patient is unable to sleep on her
first night of hospitalization. She appears restless and anxious.
40. A client with cervical traction has been on bed rest for two
weeks. The traction is discontinued and the client needs to ambulate.
Prior to getting the client out of bed, what is the initial action by the
nurse?
a. Assess lower leg muscle strength
b. Raise the head of the bed slowly
c. Provide the client with a cane
d. Get a neck brace for the client
Answer: B
Rationale: Orthostatic hypotension is a blood pressure that falls when
the client sits or stands.It may occur if the client has been on bed rest.
It is the result of the peripheral vasodilatation in which blood leaves
the central organs, especially the brain, and moves to the periphery,
often causing the person to faint. To decrease the problem, gradually
elevate the head of the bed to assist the client to asitting position
.Kozier FUNDAMENTALS OF NURSING 7th Ed p 511 ( Source: Hogan
NURSING FUNDAMENTALS p291)
The nurse should also assess the strength of the leg muscles but this is
not the priority. A neck brace may not be ordered.
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41. Although clients may exhibit calm behavior, physical evidence of
stress may still be manifested by
a. decreased heart rate
b. hyperventilation
c. dilated peripheral blood vessels
d. constricted pupils
Answer: B
Rationale: The rate and depth of respirations increase because of
dilation of the bronchioles, promoting hyperventilation. The other
physiologic indicators of stress are pupils dilate to increase visual
perception when serious threats to the body arise, the heart rate and
cardiac output increase to transport nutrients and by products of
metabolism efficiently, skin is pallid because of constriction of
peripheral blood vessels, an effect of norepinephrine., urinary output
decreased (Source: Kozier FUNDAMENTALS OF NURSING 7th Ed p 1016)
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44. A nurse is performing oropharyngeal suctioning on an unconscious
client. Which of the following actions is safe?
a. Gently rotate the catheter while applying suction.
b. Apply suction for 5 seconds while inserting the catheter and
continue for another 5 seconds before withdrawing.
c. Insert the catheter approximately 20 cm while applying suction.
d. Allow 20 – 30 seconds intervals between each suction, and limit
suctioning to a total of 15 minutes.
Answer: A
Rationale: Gentle rotation ensures that all surfaces are reached and
prevents trauma to any one area caused by prolonged suctioning. In
oropharyngeal suctioning, the catheter should be advanced 10 to 15
cm; 20 cm is the distance for tracheal suctioning. 15 minutes of
suctioning and applying suction while inserting the catheter can cause
trauma to the mucous membranes.(Source: Mary Ann Hogan NURSING
FUNDAMENTALS Prentice Hall Nursing Reviews and Rationales p204)
46. Which statement indicates a need for further teaching of the home
care client with a long term indwelling catheter?
a. “Intake of cranberry juice may help decrease the chances of
developing infection.”
b. “I will keep the collecting bag below the level of the bladder at all
times.”
c. “I should use clean technique when emptying the collecting bag.”
d. “Soaking in warm tub bath may ease the irritating feeling from
having a catheter.”
Answer: D
Rationale: Sitting in a tub allows bacteria easier access into the
urinary tract. Take a shower rather than a bath tub. Acidifying the
urine of clients with retention catheter may reduce the risk of urinary
tract infection and calculus formation. Foods such as eggs, cheese,
meat poultry, whole grains, cranberries, plums and prunes and
tomatoes tend to increase the acidity of the urine.
Keep the urine drainage bag below the level of the bladder.
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Follow instruction for clean technique. Wash hands well with soap and
warm water prior to handling or performing catheterization.(Source:
Kozier FUNDAMENTALS OF NURSING 7th Ed p 1278)
48. The structure of the nervous system that controls sleep is the:
a. hypothalamus c. medulla oblangata
b. reticular formation d. cerebral cortex
Answer: B
Rationale: (Reticular formation assist in regulation of skeletal motor
movement and spinal reflexes) one of the components of reticular
formation is the reticular activating system (RAS), which controls the
sleep wake cycle and consciousness.
A – hypothalamus regulates stress response, sleep, appetite, body
temperature, fluid balance and emotions (source: Saunders
Comprehensive Review, p. 807, 2003)
C – controls HR, respiration; primary respiratory center (Source: FNPby
Udan yr 2001,p. 83)
D – is responsible for the conscious activities of the cerebrum (source:
Saunders Comprehensive Review, p. 807, 2003)
50. These are characteristics most patients associate with sleep and
rest, except:
a. feeling of acceptance
b. assured of response to call when needed
c. free from discomfort
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d. bedtime medications received on time
Answer: D
Rationale: Schedule meds on time especially diuretics to prevent
interruption of sleep
A- decrease stress on the psychological part of the client
C-creates a restful environment
54. The nurse will remove the heating pad after a 30 minute
application, when the client requests to leave it in place. The nurse will
explain that
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a. It will be acceptable to leave the pad in place if the temperature is
reduced to between 40.6 – 46 C ( 105 and 115 ).
b. It will be acceptable to leave the pad in place for another 30
minutes if the site appears satisfactory when assessed.
c. heat application for longer than 30 minutes can actually cause the
opposite effect ( constriction ) of the one desired ( dilation ).
d. it will be acceptable to leave the pad in place as long a it is moist
heat.
Answer: C
Rationale: The rebound phenomenon occurs at the time the
maximum therapeutic effect of the hot or cold application is achieved
and the opposite effect begins. If the heat application is continued, the
client is at risk for burns because the constricted blood vessels are
unable to dissipate the heat adequately via the blood circulation.
(Source:Kozier FUNDAMENTALS OF NURSING 7th Ed p 885)
56. Which of the following sounds would the nurse expect to find on
auscultation of normal lung?
a. hyperresonnance over the left lower lobe
b. tympany over the right upper lobe
c. dullness above the left 10th intercostals space
d. resonance over the left upper lobe
Answer: D
Rationale: Resonance over the left upper lobe - Percussion notes
resonate down to the 6th rib at the level of the diaphragm but are flat
over areas of heavy muscle and bone, dull on areas over the heart and
the liver, and tympanic over the underlying stomach.Kozier p579
57. For accurate inspection of body parts during PE, the important
principle to observe is:
a. adequate exposure of all body surfaces c. positioning
b. good lighting d. ensure detailed explanation
of the procedure
Answer: C
Rationale: Correct positioning elicits correct result during PE. For
example, if the client is being examined for chest and lungs, the client
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should be positioned sitting on a chair or bed to get accurate results or
to allow full lung expansion and better visualization of upper body
symmetry. (source: MS by Black, 6th ed., p. 181)
A- only the part of the body needed to be examined should be
exposed, drape the rest of the body appropriately
B- PE is conducted in a quiet, well-lit room with consideration to client’s
privacy and comfort
D- provides simple, short and clear explanations of the procedures to
the client to avoid anxiety and encourage cooperation
(Source: Lippincott Manual of Nursing Practice, 7th ed., p.51)
58. In physical examination, less tender body areas are palpated first
to:
a. reduce patient’s apprehension c. properly positioned client
b. ensure patient’s cooperation d. obtain accurate findings
Answer: D
Rationale: Less tender areas should always precede because heavy
pressure on the fingertips can dull the sense of touch giving inaccurate
results. The effective of palpation depends largely on the client’s
relaxation. Nurses can assist a client to relax by (a) draping the client
appropriately, (b) positioning comfortably (c) ensuring that their own
hands are warm before beginning, and (d) commencing palpation with
areas that are not painful. (source: FNP by Kozier, 5th ed., p. 469)
59. You are going to assess patient’s lung sounds. Which of the
following techniques of PE will you use?
a. percussion and auscultation
b. inspection, palpation, percussion, auscultation
c. inspection, auscultation, percussion, palpation
d. auscultation, percussion, palpation
Answer: A
Percussion normally reveals resonance over symmetric areas of lung.
Percussion sound may be altered by poor posture and/or presence of
excessive tissues. On auscultation, breath sounds are noted with the
use of stethoscope.
You can’t assess lung sounds through palpation (touching) or
inspecting (use of sense of sight)
(source: Lippincott Manual of Nursing Practice, 7th ed., pp. 65-66)
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61. Your client is for routine fecalysis. Which of the ff results would
not be normal?
a. odor – foul-smelling c. (+) dead bacteia
b. amorphous phosphates (+) d. (+) mucus
Answer: D
Rationale: Presence of mucus in the stool from routine fecalysis may
indicate infection such as chronic ulcerative colitis and shigellosis
A, B, D are normal to be present in stool
(Source: Lippincott Manual of Nursing Practice, 7th ed., p. 572)
62. Result of the lab test of the patient show his total serum Calcium is
4.0 mEq/L. the normal serum calcium in an adult is
a. 4.5 – 5.5 mEq/L c. 1.5 – 2.5mEq/L
b. 3.5 – 4.5 mEq/L d. 9.5 – 10.5mEq/L
Answer: A
Rationale: C- is the normal lab value of Mg
B & D are distractors.
(source: FNP by Udan, yr 2001, p.265)
64. Richard has an oxygen therapy given via facemask. The primary
effect of oxygen therapy is to:
a. increase oxygen in the tissues and cells
b. increase oxygen carrying capacity of the blood
c. increase respiratory rate
d. increase oxygen pressure in the alveolar sac
Answer: A
Rationale: Inadequate oxygen delivery to the body tissues may
immediately predispose the client to hypoxia so the client needs
oxygen therapy to increase oxygen in the tissues and cells.
B, C, D are all secondary effects of oxygen therapy. Before these
happen choice A should took place.
(Source: Anatomy and physiology by E. Marieb, 398)
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A and C – are useful in promoting lung expansion; they require doctor’s
order. Nurses should first employ nonpharmacologic interventions to
promote lung expansion and should be independent functions.
B-Loosens secretions in the lungs but still the client should cough out
the secretions to promote better lung expansion
67. A 7 year old Filipino client has been diagnosed with leukemia.
What intervention would be appropriate when considering the client’s
culture?
a. Ban all visits from alternative healers.
b. Make diet selections for the child and family.
c. Encourage visits from extended as well as immediate family.
d. Limit all visitors, including extended family.
ANSWER: B
Rationale: To gain a client’s trust, respect may be conveyed even if
there is disagreement with the belief expressed. Introductions and
further assessment are important but ineffective if respect is not
conveyed. Notifyng the physician does not have priority at this time.
Mary Ann Hogan NURSING FUNDAMENTALS Prentice Hall Nursing
Reviews and Rationales p 131
68. A nurse is obtaining the pulse of a client and found the rate to be
above normal. How would the nurse document this finding?
a. Arrythmia
b. Tachycardia
c. Tachypnea
d. Hyperpyrexia
Answer: B
Rationale: Tachycardia is the correct terminology for an elevated
heart rate. Tachypnea is an elevated respiratory rate. Arrythmia is an
irregular rhythm of the heartbeat, and hyperpyrexia is a very elevated
body temperature. Mary Ann Hogan NURSING FUNDAMENTALS Prentice
Hall Nursing Reviews and Rationales p 161
69. A night shift nurse has placed restraints on the following clients.
In which situation would the use of restraints be appropriate?
a. A client who is severely anxious about test results.
b. A postoperative client who is alert but still weak.
c. A child who is hyperactive.
d. A child scratching the incision site postoperatively.
ANSWER: D
Rationale: One of the purposes of restraints should be to prevent
interruption of therapy such as the use of dressings. Restraints should
not be used for the convenience of the staff as in option c, nor should
they be used because a client is weak or distraught (option b). The
client in option a has no need for restraints. (Source: Mary Ann Hogan
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NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p203
22
hematocrit level, clotting studies and serum electrolyte. In albumin
globulin ratio the blood is drawn without fasting or special preparation.
(source: MS by Black, 6th ed., p. 1082)
B and C-Requires 8 hours of fasting before the test.
D-Requires 4 hours of fasting before sampling
(Source: Saunders comprehensive exam 2nd ed. p. 90-93)
75. Which of the ff. statement is true about rectal tube insertion?
a. the rectal tube may remain the colon for 2-3 hours to achieve the
desirable effect
b. the rectal tube should remain the colon no longer than 30 minutes
and reinserted 2-3 hours later
c. the rectal tube should remain in the colon only for 5-10 minutes to
prevent damage
d. the rectal tube may remain in the colon for 24 hours or until the
effect has been achieved
Answer: B
Rationale: Insertion of rectal tube beyond 30 mins.will damage the
rectal sphincter control.
It is intermittently reinserted into 2-3 hours to achieve desirable effect.
A, C, D are not applicable
(Source: FNP by Kozier, 5th ed., p. 207)
76. Daniel, 50 years old has urinary incontinence. His urinary output
for the past 3 hours is 60 ml. What should the nurse do?
a. stimulate the patient to urinate
b. palpate the patient’s hypogastrium
c. position the patient o his left
d. inform the head nurse about the condition
Answer: B
Rationale: The nurse should first assess if the client has a distended
bladder by palpating the hypogastrium before doing options A and D.
C-Position in Fowler’s, Flexes hips and knees.
77. Which of the ff. is the rationale for measuring fluid intake and
output? To monitor:
a. amount of fluid and electrolyte c. patient’s renal function
b. patient’s VS d. patient’s weight
Answer: A
Rationale: The measurement and recording of fluid intake and output
provides important data about the clients fluid electrolyte balance
B-Changes in VS may indicate fluid and electrolyte, acid base
imbalances or compensating mechanisms for maintaining balance
C-Is the rationale for measuring hourly urine output
D-Can provide assessment of the client fluid status
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(Source: FNP by Kozier 7th ed., p.1067-1068)
78. Pain is one of the patient’s major problems. Which of the ff.
statement is not true?
a. utilize various types of pain relief measures if necessary
b. utilize measures that the nurse believes to be effective
c. if therapy proves ineffective at first, change with another relief
measure
d. pain tolerance varies greatly among individuals
Answer: B
Rationale: Use pain-relieving measures that the CLIENT believes are
effective. It has been recognized that clients are usually the authorities
on their own pain. Thus, incorporating the clients’ measures in to a
pain relief plan is sensible unless they are harmful.
A-It is thought that using more than one measure has an additive
effect in relieving pain. Because client’s pain may vary throughout a
24-hour period, different types of pain relief are often during that time.
C-Sometimes strategies need to be tried and changed until the client
obtains effective pain relief.
D – is true
(Source: FNP by Kozier, 5th ed., p. 994)
79. Heat and cold application can relieve pain. The application of cold
gives the primary effects of:
1. vasoconstriction a. 1,2
2. vasodilation b. 1,4
3. tissue damage c. 2,3
4. slowed metabolism d. 1,3
Answer: B
Rationale: These are both physiologic effects of cold applications to
relieve pain. Cold has a vasodilating effect. Tissue damage could occur
if either heat or cold is applied beyond 30 minutes.
Cold application in general is safer than heat. It is done during the first
24 hours; heat application follows after 24 hours. Heat application
usually requires doctor’s orderDuring heat and cold application, check
the area every 15 to 20 minutes. Increased pain and swelling,
numbness, extreme redness and mottling may indicate the need to
discontinue the treatment.(Source: FNP by Udan, yr 2001, p.34)
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b. offer small, frequent feedings d. administer vitamin
substitute
Answer: D
Rationale: Administering vitamins substitute food is not enough to
replace the fluid and electrolytes lost and to increase weight.
B- offering small frequent meal promotes weight gain
A and C- Increase appetite
83. What nursing diagnosis would most likely be appropriate for the
absence of hair on a 72 year old male client’s legs?
a. Risk for infection
b. Tissue perfusion, altered: peripheral
c. Fluid volume deficit
d. Altered nutrition: less than body requirements
Answer: B
Rationale: During physical assessment, the nurse inspects the
client’s legs for hair distribution. The most common reason for shiny
skin and a complete absence of hair is poor circulation related to
peripheral vascular disease (PVD). The other nursing diagnosis should
not affect air distribution. Mary Ann Hogan NURSING FUNDAMENTALS
Prentice Hall Nursing Reviews and Rationales p63
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client sitting upright. Mary Ann Hogan NURSING FUNDAMENTALS
Prentice Hall Nursing Reviews and Rationales p 63
85. While on her way home, a nurse stops and provides first aid to a
motor vehicle accident. The nurse knows that this action is protected
by the Good Samaritan law. Which statement about Good Samaritan
law is correct?
a. It does not provide liability for the nurse responding to an
emergency.
b. It hinders nurses from providing help during an accident.
c. It was created specifically for RN’s and LPN’s.
d. It differs from state to state.
Answer: D
Rationale: It differs from state to state and should be reviewed by
the practicing RN. Good Samaritan laws are designed to protect
healthcare professionals who offer assistance during an emergency
and may apply to various licensed personnel. . (Source: Mary Ann
Hogan NURSING FUNDAMENTALS Prentice Hall Nursing Reviews and
Rationales p104)
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(source: FNP by Udan, yr 2001, p.81)
91. In using the three part diagnostic statement in the PES format ,
which is correct?
a. The three part diagnostic statement is always more accurate.
b. The three part diagnostic statement is shorter.
c. The three part diagnostic statement applies to risk and wellness
diagnoses also.
d. The three part diagnostic statement documents the indicators of the
problem.
Answer: D
Rationale: The three part diagnostic statement documents the
indicators of the problem.
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 217)
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Answer: A
Rationale: Attentive listening is listening actively, using all the
senses, as opposed to listening passively with just one ear. It is
probably the most important technique in nursing and is basic to all
other techniques. Attentive listening is an active process that requires
energy and concentration. It involves paying attention to the total
message, both verbal and non verbal, and noting whether these
communications are congruent. Attentive listening means absorbing
both the content and the feeling the person is conveying, without
selectivity.The listener does not select or listen solely to what the
listener wants to hear; the nurse focuses not on the nurse’s own needs
but rather on the client’s needs. Attentive listening conveys an attitude
of caring and interest, thereby encouraging the client to talk. (Source:
Kozier FUNDAMENTALS OF NURSING 7th Edition p 429)
93. A client in pain is struggling with cancer. The nurse points out “It is
normal to feel frustrated about the discomfort.” What skill in the
working phase of the helping relationship is the nurse using?
a. confrontation
b. concreteness
c .respect
d. genuineness
Answer: D
genuineness
(Source: Kozier FUNDAMENTALS OF NURSING 7th Edition p 323)
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96. A widely used method of organizing and recording data about a
client which is quickly accessible to all members of the health team,
usually during endorsement procedure is:
a. Kardex c. SOR
b. POR d. Computer
Answer: A
Rationale: B-in problem oriented medical record, data about the
client are recorded and arranged according to the source of the info.
The record integrates all data about a problem, gathered by the
members of the health team. Four basic components: (1.) data base,
(2) problem list, (3) initial list of orders or care plans, and (4) progress
notes which includes nurse’s or narrative notes, flow sheets and
discharge notes or referral summaries
C- in source oriented medical record, each person or department
makes notations in a separate section/s of the client’s chart. Also
called traditional client record. Five components are: (1) admission
sheet; (2) physician’s order sheet; (3) medical history sheet; (4) nurses
notes; and (5) special records and reports (e.g. referrals, X-ray report,
lab. findings)
D- currently, nurses use computers to assist with practice in clinical
settings. In a hospital setting, computers are used by nurses to: enter
orders and retrieve results from various ancillary departments,
document client progress using critical pathways or other
methodologies, track medication administration and enter client
assessments
(source: FNP by Taylor, p. 230)
(source: FNP by Udan, yr 2001, p.52-53)
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100. All but one is true of GAS?
a. adaptation basically is protective
b. it is a sequence of behavior involving the whole body
c. it is an abnormal alteration in body function due to stress
d. it is essentially a neuroendocrine response
Answer: C
Rationale: It’s a normal alteration in body function due to stress
B- man whenever he responds to stress, the entire body is involved
D- The GAS occurs with the release of certain adaptive hormones and
subsequent changes in the structure and chemical composition of the
body
Stages of GAS:
I. stage of alarm – the person becomes aware of the presence
of threat or danger; levels or resistance are decreased;
adaptive mechanisms are mobilized (fight-or-flight reaction);
if the stress is intense enough, even at the stage of alarm,
death may ensue.
II. stage of resistance- characterized by adaptation; levels of
resistance are increased; the person
moves back to homeostasis
III. stage of exhaustion- results from prolonged exposure to
stress and adaptive mechanisms can no longer persist; unless
other adaptive mechanisms will be mobilized, death may ensue.
(source: FNP by Udan, yr 2001, p.26)
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