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Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 1 (1)
Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 1 (1)
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C. Change agent
D. Caregiver - -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
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C. Change agent
D. Caregiver - -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
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C. Competent
D. Advanced beginner - -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.
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C. Tertiary prevention
D. Rehabilitation - -B. Secondary prevention
✅✅
C. Competent
D. Advanced beginner - -D. Advanced beginner
✅✅
C. Syndrome nursing diagnosis
D. Risk nursing diagnosis - -C. Syndrome nursing diagnosis
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C. 40.03 degrees C
D. 38.01 degrees C - -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.
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C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning. - -C. Patient's NGT was
removed 2 hours ago
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
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C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site - -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
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C. Capillary refill greater than 3 seconds and buccal cyanosis
D. Hemoglobin of 13 g/dl - -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.
✅✅-C.
C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing -
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
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D. Incorporation of both nursing and medical diagnoses in patient care -
-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.
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C. Disconnect the catheter from the tubing and get urine
D. Aspirate urine from the tubing port using a sterile syringe - -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.
✅✅
C. Doctor and family
D. Nurse and doctor - -B. Nurse and patient
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
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C. Gurgles
D. Vesicular - -A. Wheezes
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C. Decreased serum sodium levels
D. Decreased urine output - -D. Decreased urine output
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C. Instill 60ml of water into the NGT after feeding
D. Assist the patient in fowler's position - -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
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D. Press the tragus of the ear a few times to assist flow of medication into the
ear canal - -B. Instill the medication directly into the tympanic membrane
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shallow breathing and temporary apnea
D. Increased rate and depth of respiration - -D. Increased rate and depth
of respiration
The nurse is aware that Bell's palsy affects which cranial nerve?
A. 2nd CN (Optic)
B. 3rd CN (Occulomotor)
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C. 4th CN (Trochlear)
D. 7th CN (Facial) - -D. 7th CN (Facial)
Bells' palsy is the paralysis of the motor component of the 7th cranial nerve,
resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat
naso-labial fold and loss of taste on the affected side of the face.
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C. Intestine
D. Lung - -D. Lung
Resonance is loud, low-pitched and long duration that's heard most commonly
over an air-filled tissue such as a normal lung.
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C. 3-day diet recall
D. Eating style and habits - -C. 3-day diet recall
3-day diet recall is an example of dietary history. This is used to indicate the
adequacy of food intake of the client.
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C. 9 months
D. 1 year - -B. 6 months
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C. Algor mortis
D. none of the above - -C. Algor mortis
Algor mortis is the decrease of the body's temperature after death. Livor
mortis is the discoloration of the skin after death. Rigor mortis is the stiffening
of the body that occurs about 2-4 hours after death.
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C. Megaloblastic anemia
D. Pernicious anemia - -C. Megaloblastic
Pia's serum sodium level is 150 mEq/L. Which of the following food items does
the nurse instruct Pia to avoid?
A. Broccoli
B. Sardines
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C. Cabbage
D. Tomatoes - -D. Sardines
The normal serum sodium level is 135 to 145 mEq/L, the client is having
hypernatremia. Pia should avoid food high in sodium like processed food.
Broccoli, cabbage and tomatoes are good source of Vitamin C.
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C. Collaborative
D. Professional - -A. Independent
✅✅
C. Angina
D. Chronic Renal Failure - -A. Hypothermia
Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus,
Angina and Chronic Renal Failure are medical diagnoses.
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C. Bulla
D. Macule - -B. Vesicle
✅✅
C. Second right intercostal space at the sternal border
D. Second left intercostal space at the sternal border - -A. 5th left
intercostal space along the midclavicular line
The S1 heart sound is best heard at the apex of the heart, at the fifth
intercostal space along the midclavicular line. (An infant's apex is located at
the third or fourth intercostal space just to the left of the midclavicular line)
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C. Temporal artery
D. Inguinal site - -B. Apex of the heart
The best site for verifying a pulse rate is the apex of the heart, where the
heartbeat is measured directly.
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C. Hyperextend the patient's neck
D. Adduct the patient's shoulder - -A. Place the patient's feet in
dorsiflexion
Anatomic alignment prevents strain on body parts, maintains balance, and
promotes physiologic functioning. To promote this position, the nurse should
place the feet in dorsiflexion (at right angles to the legs).
Postural drainage is best performed before, rather after meals to avoid tiring
the patient or inducing vomiting. The patient's safety supersedes the
convenience in scheduling this procedure.
Mr. Jose is admitted to the hospital with a diagnosis of pneumonia and COPD.
The physician orders an oxygen therapy for him. The most comfortable
method of delivering oxygen to Mr. Jose is by:
A. Croupette
B. Nasal cannula
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C. Nasal catheter
D. Partial rebreathing mask - -B. Nasal cannula
The nurse's main priority when caring for a patient with hemiplegia?
A. Educating the patient
B. Providing a safe environment
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C. Promoting a positive self-image
D. Helping the patient accept the illness - -B. Providing a safe
environment
A patient with hemiplegia (paralysis of one side of the body) has a high risk of
injury because of his altered motor and sensory function, so safety is the
nurse's main priority.
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C. Jaundice
D. Pallor - -A. Flush
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C. Give the patient a glass of warm milk before bedtime
D. Close the patient's door from 9pm to 7am - -C. Give the patient a glass
of warm milk before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural
sedative.
If a patient sues a nurse for malpractice, the patient must be able to prove:
A. Error, proximal cause, and lack of concern
B. Error, injury and proximal cause
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C. Injury, error and assault
D. Proximal cause, negligence and nurse error - -B. Error, injury and
proximal cause
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C. Florence Nightingale
D. Sister Callista Roy - -A. Martha Rogers
✅✅
C. Florence Nightingale
D. Sister Callista Roy - -B. Dorothea Orem
Dorothea Orem's conceptual model is based on the premise that all persons
need to achieve self-care. She also views the goal of nursing as helping the
patient to develop self-care practices to maintain maximum wellness.
The average daily amount of urine excreted by an adult is:
A. 500 to 600 ml
B. 800 to 1,400 ml
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C. 1,000 to 1,200 ml
D. 1,500 to 2,000 ml - -D. 1,500-2,000 ml
An adult's average urine output ranges between 1,500 and 2,000 ml/day.
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C. External hemorrhoids
D. Gastrostomy feeding tubes - -B. Nasal packing
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hypochondriac, left hypochondriac and umbilical regions
D. Rectum, pancreas, stomach and liver - -A. Right lower quadrant, right
upper quadrant, left upper quadrant, left lower quadrant
This sequence follows the anatomy of the bowel. The lobes are parts of the
lung. the right and left hypochondriac and the umbilical area are three of the
nine regions of the abdomen.
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C. Decreased peristalsis and positional discomfort
D. Increased colon motility - -C. Decreased peristalsis and positional
discomfort
✅✅-B. Activity
C. Love
D. Self esteem -
✅✅-A.
C. Irrigation of the stomach with a solution
D. A surgical opening through the abdomen to the stomach -
Administration of a liquid feeding into the stomach
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C. Evaluation
D. Validation - -D. Validation