Funda Ratio 003

FUNDA – 003 ANSWERS AND RATIONALE
SAFE NURSING PRACTICE

1. CORRECT ANSWER: D
A client who has undergone oral surgery should not have the temperature taken by the oral method . The client is exhibiting signs
and symptoms of elevated body temperature, and the rectal method is the best choice. A forehead temperature strip and the
axillary method does not give as precise measurements as the rectal route in a client at risk for infection or other causes of
hyperthermia.
Reference: kozier, B., Erb, G., Berman, A., & Snyder, S.J. (2004). Fundamentals of nursing: concepts, process and practice (7th ed.).
Upper Saddle River, NJ: Pearson Education, p.491
2. CORRECT ANSWER: A
While working over the sterile field, talking should be kept to a minimum and the head should be averted from the field if talking is
necessary. The other options represent correct actions when using sterile or surgical aseptic technique.
3. CORRECT ANSWER: C
A wide base of support is achieved by spreading the feet apart to lower the center of gravity. The other responses either put the
nurse at risk for injury (option A) or do not address the issue of wide base of support.
Upper Saddle River, NJ: Pearson Education, p.1078-1079
4. CORRECT ANSWER: B
To prevent back strain for the nurse, the bed should be raised to a comfortable position. A nurse should stand with a wide base of
support, work as closely as possible to an object, and avoid twisting motions.
Upper Saddle River, NJ: Pearson Education, p. 107
Providing oral hygiene is the procedure that exposes the nurse to a client’s body fluids. The other responses do not require the use of
gloves because contact with body fluids is not a concern.
The method of choice for opening the airway is the head tilt-chin lift method. The jaw trust method should be use when neck injury is
possible. Option c is not one method for treating airway obstruction by foreign body. Option D is fictitious.
A client fall is a potential medical emergency; however the nurse’s first responsibility is ensuring the client being attended to. Sterile
equipment is considered contaminated if left unattended and therefore must be throen away (options A and D). The nurse needs to
prioritize care appropriately; thus the nurse needs to prioritize care appropriately; thus the nurse needs to repond to the client who
fell rather than continue with catheterization.
To ensure that lower extremity circulation is intact, the nurse should verify the presence of the pedal pulse. Although checking the
lower extremity temperature and measuring circumference will provide data on circulation, it does not ensure a pedal pulse is
present. It is inappropriate to notify the physician without first gathering all appropriate data.
The client with the airborne or droplet infection can spread this infection simply by breathing and requires isolation in a private room.
The client with the abdominal wound (option B) would not be as likely to spread this organism when the wound is dressed. The clients
in options A and D have no medical need for a private room.
Handwashing technique is the single most important procedure in reducing the spread of micro organism.
Upper Saddle River, NJ: Pearson Education, p.641- 642
BASIC HUMAN NEEDS
The client needs to be supervised and monitored and placed in a room that is more accessible. Assessment is needed to determine
causes of wandering. Stimulation is not necessary for a client who is a wanderer. Anti-anxiety medications may cause more
agitation, and locking other client’s rooms will not prevent the client from a wandering.
Reference: Taylor, C., Lillis, C., & LeMone,P. (2005) fundamentals of nursing: the art and science of nursing care (5th ed.) Philadelphia,
PA: Lippincott Williams & Wilkins, p. 632
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 necessary to keep equipment out of view.
Reference: Lemone, P., & Burke, K. (2004) Medical-Surgical nursing: critical thinking in client care (3rd ed.). Upper Saddle River, NJ:
Pearson Education, p. 24
In the side-lying position, fluid is more likely to flow readily out of the mouth or pool in the side in the mouth were it can be easily be
suctioned. Fowler’s position and trendelenburg are not appropriate since the unconscious client does not have control of the airway
in those positions. The supine position is unsafe as the client may aspirate the fluids.
PA: Lippincott Williams & Wilkins, p.1027
Stress and long term alcohol use increase the blood pleasure. Physical exercise increases respirations and cardiac rate, increasing
the supply of oxygen to the body. Nicotine increases blood pressure and vasoconstriction, which prevents oxygen from reaching the
different parts of the body.
PA: Lippincott Williams & Wilkins, p.1384
15. CORRECT ANSWER: C, E
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 t 10 to 15cm; 20 cm is the distance for tracheal suctioning (option A).
Fifteen minutes of suctioning (option B) and applying suction while inserting the catheter (options A and D) can cause trauma to the
mucous membrane. Oxygenating the client adds to the comfort and safety of the client.
PA: Lippincott Williams & Wilkins, p.1408-1409
Although all of the actions are appropriate, the highest priority on admission is to anticipate any emergency that may occur if
problems with the chest tubes occur, such as disconnection or accidental removal.
Delayed wound healing maybe a sign of inadequate nutritional status. protein is needed to heal wounds. All other options are signs
of adequate nutritional status.
Options A, B, and C are all normal levels, while option D is indicative of potassium depletion that occurs in severe cases of
malnutrition.
Symptoms and ways of preventing an infection are crucial for a client to understand. Performance of perennial care independently
and disposal of urinary output are not appropriate outcomes. Tub baths are to be avoided, especially in females as they may
increase the possibility of developing lower tract infections.
The foods that thicken stools are in option 2. The foods in option A increase stool odor; foods in options C and D loosen stools.
PAIN
Neuropathic pain is the result of disturbance of the peripheral or central nervous system that results in pain not associated with an
ongoing tissue damage process. It is usually described as shooting, stabbing, buring or pins and needles. It is severe in anutre and is
frequently seen in clients with AIDS. Psychogenic pain is emotionally based; referred pain is felt from a distant site than the actual
tissue damage; and phantom pain occurs after the loss of an extremity.
22. CORRECT ANSWER: B, E
The client is most likely experiencing anxiety because of fears related to the postoperative pain. the best interventions are to
encourage him to verbalize his concerns and reassure him that pain medication will be available to provide relief from discomfort.
Teaching relaxation techniques and discussing positioning requires concentration from the client that may not be possible because
of anxiety. Promoting distraction does not address his fears and thereby may lead to increased anxiety.
Pruritus and / or development of the skin rash are commonly associated with the administration of epidural opiates. This may be due
in part to histamine release. The other potential physiologic problems to be anticipated include hypotension, headache and urinary
retention. Options A, B and C do not apply.
Using the PQRST technique, aching would describe the quality (Q) of pain the client is experiencing. Severe would fall under the
category of (S), intermittent indicates the timing (T) of the pain, and chronic reflects the pain.
Research has shown that small, frequent doses of an opioid as administered through PCA provide better pain relief and less total
medication than with traditional intramuscular (IM) injection used every 3 to 4 hours. Only the client should control the push button.
The goal of PCA is to provide relief of discomfort; however, with movement, stress, procedures, and so on, the client may still
experience periods of pain. The pump device is regulated to avoid overdosing and will limit the amount of medication the client
can receive within a given timeframe. Pushing the button after a maximum dose has been infused will not result in the client
receiving more medication.
According to JCAHO pain standards, if a facility cannot treat a client for pain, the individual must be referred to a facility that can
provide the skill. The physician may not be able to extend hospitalization because of insurance limitations (option A). It is long term
care facility’s decision and responsibility to become prepared to provide a new service (option B). Private duty nurses may be cost
prohibitive for the family, and the long term care facility may not have the resources needed to provide safe care for his client
(option D)
Relaxation exercise such as a guided imagery enhances other pain-relief measures to promote comfort of the client. They offer the
client the opportunity to participate actively in pain control. Complementary therapies for pain control should not be used as
substitutes for analgesia as these measures do not decrease pain sensation.
The regularity of pain assessment depends on the degree to which the client’s condition and/ or pain status is changing. More
rapidly progressive disease requires more frequent client assessment. Options A, B and C all reflect clients with recurrent, long
standing problems. Their pain should be thoroughly assessed and documented, but option D reflects the client with the most rapidly
changing condition that would require the most frequent reassessment.
Although option 1,2, and 4 may be accurate for this particular client, the best choice for the nurse is to act based directly on the
clients verbal report.
The patch is placed every 72 hours over non hairy, non-edematous skin with good capillary flow (often over the torso, shoulders, or
upper arms). Following mastectomy, the potential for lymphedema would contraindicate using upper arms because circulation
would be compromised; thus distribution of the medication would be impaired. The presence of an IV catheter or use of a trapeze
bar should not affect the site.
PERI-OPERATIVE NURSING
Option A is not the best question initially as it focuses not on the client but on the doctor. Option B is not appropriate initial question.
Option D is challenging and not appropriate as an initial question. Option 3 is correct as it is exploratory in nature and will provide a
basis for further communication for the client.
General anesthetics produce central nervous system depression so client do not feel the pain of surgery. Respiratory and circulatory
depression is a disadvantage of general anesthesia because there is a greater risk for complications, especially for clients with
chronic illnesses. General anesthetic agents are rapidly excreted and produce amnesia.
33. CORRECT ANSWER: B, E,
Benzodiazephines such as lorazepam and diazepam decrease anxiety and produce side effects such as hypotension and sedation.
Major tranquilizers such as chlorpromazine produce extrapyramidal symptoms but benzodiazepines do not. Hypocalcemia is not an
adverse effect of this class of drugs.
An increased hemoglobin and hematocrit may be a result of dehydration. Immune deficiency is an indication of decreased WBC
count (option A), while an increased in electrolytes such as potassium, sodium or chloride indicate kidney dysfunction (option B).
Malignancy may be suspected in increased platelet count (option C)
The anesthetic agent is injected into the subarachnoid space for spinal anesthesia and into the epidural space (which is outside the
dura matter) in epidural anesthesia. Regional anesthesia can include local and topical anesthesia or nerve blocks and do not
require clients to have sedation or produce amnsesia.
Option A is the correct answer as in this position, gravity keeps the tongue forward, which prevents aspiration. A pillow would
elevate the head (option B; the semiprone position is unsafe in most cases as it may interfere with breathing (option C). A dorsal
recumbent position does not protect the client from risk of aspiration because secretions coul pool at the back of the throat
Excessive bloody drainage on dressings or the bedclothes often underneath ( because of Gravity) the client indicates hemorrhage.
This technique would not be useful in determining tube drainage, fluid balance and in general sense or perspiration.
Option B is the correct answer as the client is un able to retain the information and therefore has a deficiency in knowledge base.
Placement of surgical drains will allow for drainage of excessive fluid or possibly purulent material that may have accumulated
during the surgery.
Option B could indicate wound infection. All other options indicate normal wound healing or characteristics.
SKIN INTEGRITY, PERCEPTION AND MOBILITY
41. CORRECT ANSWER: A, D
Orthostatic intolerance or hypotension may occur if the client has been on bed rest. To decrease the problem, gradually elevate
the head of the bed assist the client to a sitting position.
Presbycusis is the hearing loss associated with aging. Presbyopia is the in ability to focus on close objects; this condition normally
accompanies aging.
Myopia or nearsightedness is a condition in which light rays come into focus in front of the retina it is treated with eye glasses or
contact lenses.
A wet-to-damp dressing debrides the wound. As the dressings partially dries necrotic debris will adhere to the dressing. When the
dressing is removed dead tissue will be removed also.
Near the end of the inflammatory phase of wound healing, protein dries out at the top of the wound, forming a scab.this scab
provides safety for the wound because the first line of defense, the skin, is again covered.
To promote healing, the client should eat a diet high in protein and vitamin c.
The braden scale evaluates 6 factors: sensory perception, moisture, activity, mobility, nutrition, and friction / shear each factor can
receive a score from 1 to 4 except friction/ shear.
Passive range of motion is exercise conducted with the assistance of another individual option b, while active range of motion
option a is done by the client alone.
Hypoactive bowel sounds is complication of immobility it will be followed by constipation and other gastrointestinal problems.
Upper Saddle River, NJ: Pearson Education, p. 1070-1071
Contusion is a crushing of the tissues; there is no break in the skin. Therefore, this wound is less likely to become infected.
MEDICATION ADMINISTRATION AND INTRAVENOUS INFUSION
51. CORRECT ANSWER: A, C, D
Strict aseptic technique is always required for the changing of central line tubing and / or dressing to prevent bloodborne infection.
0.9% sodium chloride (normal saline) is the only solution that can be administered with blood or blood products.
Infiltration is leakage of fluid into the surrounding tissues, resulting in edema around the insertion site, blanching, and coolness of skin
around the site.
Erythema and edema are consistent with phlebitis, an inflammation of the vein wall. Continuing the infusion at the site would only
worsen the phlebitis.
Convert first the unit grain (gr) into gram (gm). recall that in the aphotecary system, 1g rain =60mg. thus, the 10 grain can be
converted to 600 mg. If the desired dose is 325mg, just divide it to the stock dose which is 600mg multiplied by the vehicle (1 tablet)
If blood returns while aspiring during an IM injection, the nurse should discharge and prepare a new injection.
Tourniquets and the ports of standard IV tubing are made of latex. A blood pressure cuff can be used as alternative method of vein
distention.
Clients should be instructed to hold inhaler 2 inches away from mouth, hold the breath for 10 seconds after inhalation, slowly exhale
through pursued lips, and wait 2 minutes between puffs.
59. CORRECT ANSWER: C, E
When medication are administered enterally and cannot be administered with tube feedings, it is best to stop the tube the tube
feeding for at least 30 minutes prior to and after the administration of the medication.
A client has the right to refuse a medication regardless of how important it may be to his or her health. Withholding the medication
because of client refusal is not an incident and does not require an incident report, but it should be documented and report to the
prescriber.

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FUNDA – 003 ANSWERS AND RATIONALE

SAFE NURSING PRACTICE

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