FUNDAMENTALS OF NURSING CONCEPTS 1

Nicanor M. Domingo III, RN, (MAN)c

1.) Which of the following is incorrect statement of nursing diagnosis? A.) High risk for ineffective airway clearance related to pneumonia B.) High risk for injury related to dizziness C.) Constipation related to decreased activity and fluids as manifested by small, hard, formed stool every three days D.) Anxiety related to insufficient knowledge regarding surgical experience

 ANS: A > is incorrect statement of nursing diagnosis (refer to NANDA, appendix A). B,C and D are correct statement of nursing diagnosis.

 2.) Which of the following would NOT be a basis for establishing priorities in client care? A.) Actual problems take precedence over potential concerns B.) Attend to equipment and contraptions first, such as IV fluids, urinary catheter, drainage tubes, before the client C.) Airway should always be given highest priority D.) Clients with unstable condition should be given priority over those with stable conditions.

 ANS: B > Attend to client first before equipment. A, C and D are basis for establishing priorities in client care

 3.) Which of the following is an incorrect statement of outcome procedure? A.) Ambulates 30 feet with cane before discharge B.) Discusses fears and concerns regarding the surgical procedure during preoperative teaching C.) Demonstrates proper coughing technique after the teaching session D.) Reestablishes normal pattern of bowel elimination

 ANS: D > Outcome criteria should be specific, measurable, attainable, realistic and timebound. A, B and C are correct statements of outcome criteria

 4.) The primary factor responsible for body heat production is: A.) Metabolism B.) Release of thyroxine C.) Thyroxine output D.) Muscle activity

 ANS: A > The primary factor responsible for body production is metabolism

5.) The heat-regulating center is found in the: A.) Medulla oblongata B.) Thalamus C.) Hypothalamus D.) Pons

 ANS: C > The heat-regulating center is found in the hypothalamus

 6.) A process of heat loss which involves the transfer of heat from one surface to another is: A.) Radiation B.) Conduction C.) Convection D.) Evaporation

 ANS: B > Conduction is the process of heat loss which involves the transfer of heat from one surface to another

 7.) The following statements are true about body temperature EXCEPT: A.) Core body temperature measures the temperature of deep tissues B.) Highest body temperature is usually reached between 8:00 P.M. to 12:00 M.N. C.) Elderly people are at risk of hypothermia due to decreased thermoregulatory controls and decreased subcutaneous fats D.) Sympathetic response stimulation decreases body heat production

 ANS: D > Is incorrect statement about body temperature. Sympathetic nervous system releases norepinephrine which increases metabolic rate, thereby increases body heat production.

 8.) The client with fever had been observed to experience elevated temperature for few days, followed by 1 to 2 days of normal range of temperature. The type of fever he is experiencing is: A.) Intermittent fever B.) Relapsing fever C.) Remittent fever D.) Constant fever

 ANS: B > Relapsing fever is on-and-off fever

 9.) Which of the following is NOT an appropriate nursing action when taking oral temperature? A.) Wash the thermometer from the bulb to the stem before use B.) Place the thermometer under the tongue directed towards the side C.) Take oral temperature for 2-3 minutes D.) Take oral temperature using a thermometer with pear-shaped bulb

 ANS: D > Is not appropriate nursing action when taking oral temperature. Thermometer with pear-shaped or rounded bulb is used for rectal temperature-taking

 10.) The following are contraindications to oral temperature taking EXCEPT: A.) Dyspnea B.) Diarrhea C.) Nasal-packing D.) Nausea and vomiting

 ANS: B > Diarrhea is not a contraindication for oral temperature-taking

 11.) Which of the following nursing actions is inappropriate when taking the rectal temperature? A.) Assist client to assume lateral position D.) Lubricate thermometer with water-soluble lubricant before use C.) Hold the thermometer in place for 2 minutes D.) Instruct to strain during insertion of the thermometer

 ANS: D > Instructing client to strain during insertion of rectal thermometer is inappropriate. This may cause trauma to the anus.

 12.) The following are correct nursing actions when taking the radial pulse EXCEPT: A.) Put the palms downward B.) Use the thumb to palpate the artery C.) Use two to three fingertips to palpate the pulse at the inner wrist D.) Assess the pulse rate, rhythm, volume and bilateral equality

 ANS: B > Using the thumb when palpating pulse is incorrect nursing action. The thumb has strong pulsation and the nurse might be counting her own pulse, instead of the clients pulse

 13.) The difference between the systolic pressure and the diastolic pressure is: A.) Apical rate B.) Cardiac rate C.) Pulse deficit D.) Pulse pressure

 ANS: D > Pulse pressure is the difference between systolic pressure and diastolic pressure.

 14.) When measuring the blood pressure, the following are nursing considerations EXCEPT: A.) Ensure that the client is rested B.) Use appropriate size of BP cuff C.) Initiate and deflate BP cuff 2-3 mm Hg/sec D.) Read upper meniscus of mercury

 ANS: D > Reading the upper meniscus of mercury will yield inaccurate BP reading. BP reading is done by noting the level of the lower meniscus of the mercury.

 15.) The process involved in the exchange of gases in the lungs is: A.) Diffusion B.) Osmosis C.) Hydrostatic pressure D.) Oncotic pressure

 ANS: A > Diffusion is exchange of gases from an area of higher pressure to an area of lower pressure.

16.) The primary respiratory center is: A.) Medulla oblongata B.) Pons C.) Carotid and aortic bodies D.) Proprioceptors

 ANS: A > The primary respiratory center is the medulla oblongata. It contains the central chemoreceptors that are stimulated by high levels of carbon dioxide in the blood

 17.) Which of the following primarily affects BP? A.) Age B.) Stress C.) Gender D.) Obesity

 ANS: B > Stress is the primary factor that affects BP, because of release of norepinephrine by the sympathetic nervous system.

 18.) The following are social data about a client EXCEPT: A.) Patients lifestyle B.) Religious practices C.) Family home situation D.) Usual health status

 ANS: A > Patients lifestyle is not a social data

 19.) The systematic manner of collecting data about the client by listening to body sounds with the use of stethoscope is: A.) Inspection B.) Palpation C.) Percussion D.) Auscultation

 ANS: D > Auscultation is listening to body sounds with the use of stethoscope

 20.) The following are appropriate nursing actions when performing physical health examination to a client EXCEPT: A.) Ensure privacy of the client throughout the procedure B.) Prepare the needed articles and equipment before the procedure C.) Assess the abdomen following this sequence: right lower quadrants D.) When assessing the chest, it is best to place the client in side lying

 ANS: D > This is incorrect nursing action. The best position when assessing the chest is sitting or upright position. This allows assessment of the anterior and posterior chest

 21.) Which of the following is inappropriate nursing action when collecting clean-catch midstream urine specimen for routine urinalysis? A.) Collect early morning, first voided specimen B.) Do perineal care before collection of specimen C.) Collect 5-10 mls of urine D.) Discard the first flow of urine

 ANS: C > This is inappropriate nursing action. For routine urinalysis, 3-50 mls of urine specimen is required to yield accurate results

 22.) Which of the following nursing actions is incorrect when performing Benedicts test? A.) Collect 24-hour urine specimen B.) Ensure that Benedicts solution remains unchanged after heating it C.) Add 8-10 drops of urine D.) Interpret that the urine is negative for glucose when the color remains blue

 ANS: A > This is incorrect nursing action. When performing Benedicts test, collect secondvoided urine specimen

 23.) Heat and acetic acid test is done to determine A.) Presence of albumin in the urine B.) Presence of glucose in the urine C.) Presence of ketones in the urine D.) Presence of RBC in the urine

 ANS: A > Heat and acetic acid test is done to determine presence of albumin in the urine.

 24.) Which of the following is correct nursing action when collecting urine specimen from a client with indwelling urethral catheter? A.) Collect urine specimen from the urinary drainage bag B.) Detach the catheter from the connecting tube C.) Use sterile needle and syringe to aspirate urine specimen from the drainage port D.) Flush the catheter with sterile NSS before collection of urine specimen

 ANS: C > When collecting urine specimen from a client with indwelling urethral catheter, collect urine specimen by using sterile needle and syringe to aspirate urine specimen from the drainage port.

 25.) The following are independent nursing interventions for a febrile client EXCEPT: A.) Administer paracetamol 500 mg. tab every 4 hours PRN for temperature 38.5 C B.) Increase fluid intake C.) Promote bed rest D.) Keep the clients clothing clean and dry

 ANS: A > Administration of antipyretic to a febrile client is dependent nursing intervention, (not independent nursing intervention)

 26.) The common opening between the respiratory and digestive system is: A.) Pharynx B.) Larynx C.) Trachea D.) Bronchus

 ANS: A > The common opening between the respiratory and digestive system is the pharynx

27.) The right lung has: A.) 2 lobes B.) 3 lobes C.) 4 lobes D.) 5 lobes

 ANS: B > The right lung has 3 lobes

 28.) The amount of air that remains in the lungs after forceful exhalation is: A.) Functional residual capacity B.) Residual volume C.) Tidal volume D.) Minute volume

 ANS: B > The amount of air that remains in the lungs after forceful exhalation is residual volume

 29.) Cheyne-Stokes breathing is: A.) Slow, shallow respirations which result to inadequate alveolar ventilation B.) Difficulty of breathing in reclining position C.) Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea D.) Shallow breaths interrupted by apnea

 ANS: C > Cheyne-stokes breathing is marked waxing and waning of respirations from very deep to very shallow breathing and temporary apnea

 30.) The best position to promote maximum lung expansion is: A.) Supine B.) Retractions C.) Noisy breathing D.) Semi fowlers

 ANS: D > The best position to promote maximum lung expansion is Semi-Fowlers

 31.) The characteristic manifestation of airway obstruction is: A.) Bradypnea B.) Retractions C.) Noisy breathing D.) Tachypnea

 ANS: C > The characteristic manifestation of airway obstruction is noisy breathing.

 32.) The following are appropriate nursing interventions to promote normal respiratory function EXCEPT: A.) Adequate fluid intake B.) Minimize cigarette smoking C.) Deep breathing and coughing exercises D.) Frequent change of position among bedridden clients

 ANS: B > This is inappropriate nursing intervention to promote respiratory function. Appropriate is avoid or quit cigarette smoking, not just to minimize it

 33.) The initial manifestations of hypoxemia are A.) Restlessness, tachycardia B.) Dizziness, faintness C.) Headache, blurring of vision D.) Dyspnea, retractions

 ANS: A > The initial manifestations of hypoxemia are restlessness and tachycardia

 34.) The following are appropriate nursing actions when performing percussion, vibration and postural drainage, EXCEPT: A.) Verify doctors order B.) Perform the procedure before meals and at bedtime C.) provide good oral hygiene after the procedure D.) Each position during postural drainage should be assumed for 30 minutes

 ANS: D > This is inappropriate nursing action during chest physiotherapy. Appropriate is to assume each position during postural drainage for 10 to 15 minutes

 35.) Which of the following nursing actions is inappropriate when providing steam inhalation therapy? A.) Check doctors order B.) Cover the eyes with moist washcloth C.) Place the spout 3-4 inches away from the patients nose D.) Place the patient in semi-fowlers position

 ANS: C > This inappropriate nursing action when providing steam inhalation therapy. Appropriate is to place the spout at least 12 inches from the patients nose.

 36.) To be effective, steam inhalation should be rendered for at least: A.) 5-10 minutes B.) 15-20 minutes C.) 30-45 minutes D.) 60-70 minutes

 ANS: B > To be effective, steam inhalation should be rendered for at least 15-20 minutes

 37.) The correct pressure of the wall suction unit when suctioning an adult patient is: A.) 95-110 mm Hg B.) 100-120 mm Hg C.) 50-95 mm Hg D.) 10-15 mm Hg

 ANS: B > The correct pressure of the wall suction unit when suctioning an adult patient is 100-120 mm Hg

 38.) Which of the following is inappropriate nursing action when performing oropharyngeal suctioning? A.) Place the client in semi-fowlers or lateral position B.) Measure length of catheter from the tip of the nose to the earlobe. C.) Lubricate suction catheter with alcohol D.) Apply suction during withdrawal of the suction catheter tip:

 ANS: C > When performing oropharyngeal suctioning, it is inappropriate to lubricate catheter with alcohol. Alcohol may irritate mucous membrane of airways. Appropriate is, use sterile water or sterile NSS.

 39.) The maximum time for applying suction is: A.) 5-10 seconds B.) 10-15 seconds C.) 15-20 seconds D.) 20-30 seconds

 ANS: B > The maximum time for applying suction is 10 to 15 seconds. This is to prevent hypoxia

 40.) To evaluate effectiveness of suctioning, the nurse should primarily: A.) Auscultate the chest for clear breath sounds B.) Assess the respiratory rate C.) Check the skin color D.) palpate the pulse rate

 ANS: A > To evaluate effectiveness of suctioning, the nurse should primarily auscultate the chest for clear breath sounds

 41.) The oxygen administration device preferred for patients with COPD is: A.) Nasal cannula B.) Oxygen tent C.) Venturi mask D.) Oxygen hood

 ANS: C > Venturi mask is the preferred device for oxygen therapy among clients with COPD.

 42.) Which of the following is not to be included in the nursing interventions for a client receiving oxygen therapy? A.) Place a Non-smoking sign at the bedside B.) Place the client in semi-fowlers position C.) Place sterile water into the oxygen humidifier D.) Lubricate nares with oil to prevent dryness of the mucous membrane

 ANS: D > It is inappropriate to lubricate nares with oil when the client is receiving oxygen therapy. Oil ignites when exposed to compressed oxygen

 43.) When assessing respiration, the nurse describes the following EXCEPT: A.) Rhythm B). Effort C.) Rate D.) Depth

 ANS: C > When assessing respirations, the nurse should count the rate, not simply describe it.

 44.) The small hair-like projections that line the tracheobronchial tree, which sweep out debris and excessive mucous from the lungs are called: A.) Cilia B.) Vibrissae C.) Macrophages D.) Goblet cells

 ANS: A > Cilia are small hair-like projections that line the tracheobronchial tree

 45.) The following are appropriate nursing diagnoses for clients with oxygenation problems: A.) Ineffective airway clearance related to tracheobronchial secretions B.) Ineffective breathing pattern related to decreased energy and fatigue C.) Impaired gas exchange related to altered oxygencarrying capacity of the blood D.) All of these

 ANS: D > All of these (A,B, and C) are appropriate nursing diagnoses for clients with oxygenation problems.

 46.) The regulating center for fluid and food intake are located in their A.) Thalamus B.) Hypothalamus C.) Medulla oblongata D.) Pons

 ANS: B > The regulating centers for food and fluid intake are found in the hypothalamus

 47.) The enzyme that initiates digestion of starch in the mouth is: A.) Amylase B.) Sucrase C.) Maltase D.) Lactase

 ANS: A > The enzyme that initiates digestion of starch in the mouth is salivary amylase

 48.) Which of the following structure prevents gastric reflux? A.) Pyloric sphincter B.) Internal sphincter C.) Cardiac sphincter D.) Sphincter of Oddi

 ANS: C > The cardiac sphincter also known as lower esophageal sphincter prevents gastric reflux

 49.) Which of the following nutrients remains in the stomach for the longest period? A.) Fats B.) Proteins C.) Carbohydrates D.) Water

 ANS; A > Fats remains in the stomach for 4 to 6 hours; carbohydrates for 1 to 2 hours; protein 3 to 4 hours

 50.) The pancreatic enzyme which completes digestion of fats is A.) Amylase B.) Lipase C.) Trypsin D.) Rennin

 ANS: B > Lipase is the pancreatic enzyme that completes digestion of fats

 51.) Kwashiorkor is a condition characterized by: A.) Calorie deficiency B.) Vitamin Deficiency C.) Protein deficiency D.) Mineral deficiency

 ANS: C > Kwashiorkor is protein deficiency

 52.) Which of the following is most effective nursing measures to relieve anorexia EXCEPT: A.) Provide small, frequent feedings B.) Remove unsightly articles from the patients unit C.) Provide three full meals a day D.) Provide good hygienic measures

 ANS: A > Providing small frequent feedings is most effective nursing measure to relieve anorexia

 53.) The following factors increase calorie requirements EXCEPT: A.) Cold climate B.) Activity and exercise C.) Fever D.) sleep

 ANS: D > Sleep reduces calorie requirement by 10 to 15% . A,B,and C are factors that increase calorie requirement.

 54.) The following are good sources of calcium EXCEPT: A.) Cheese B.) Milk C.) Soy products D.) Carbonated drinks

 ANS: D > Carbonated drinks are not sources of calcium. A,B and C are good sources of calcium.

 55.) Which of the following is the richest source of iron? A.) Mongo B.) Milk C.) Malunggay leaves D.) Pechay

 ANS: A > Among these choices, mongo (a legume) is the richest source of iron. The richest source of iron is liver, next is lean meat, then legumes, then green leafy vegetables

 56.) Which of the following is a good source of vitamin A? A.) Eggs B.) Liver C.) Fish D.) Peanuts

 ANS: B > Liver is very good source of fat-soluble vitamins (A,D,E,K)

 57.) The following may be given to relieve nausea and vomiting EXCEPT: A.) Dry toast B.) Milk C.) Cold cola beverage D.) Ice chips

 ANS: B > Milk does not relieve nausea and vomiting. A,B,C may relieve nausea and vomiting

 58.) The most life threatening complication of vomiting is: A.) Aspiration B.) Dehydration C.) Fever D.) Malnutrition

 ANS: A > The most life-threatening complication of vomiting is aspiration. It causes airway obstruction.

 59.) The vomiting center is found in the ________. A.) Cerebellum B.) Hypothalamus C.) Medulla Oblongata D.) Cerebrum

 ANS: C > The vomiting center in the Medulla Oblongata

 60.) The best indicator of nutritional status of the individual is: A.) Weight B.) Height C.) Arm muscle circumference D.) Adequacy of hair

 ANS: A > The best indicator of nutritional status is the weight

 61.) To assess the adequacy of food intake, which of the following assessment parameters is best used? A.) Food preferences and dislikes B.) Regularity of meal times C.) 3-day diet recall D.) Eating style and habits

 ANS: C > Dietary diary e.g. 3-day diet recall, is the best assessment parameter for adequacy of food intake

 62.) Prolonged deficiency of vitamin B12 leads to: A.) beriberi B.) Pernicious anemia C.) Pellagra D.) Peripheral neuritis

 ANS: B > Prolonged Vit B12 deficiency results to pernicious anemia

 63.) The vitamin necessary for absorption of calcium is: A.) Vit D B.) Vit A C.) Vit C D.) Vit E

 > Vit D promotes absorption of calcium

64.) Vit. K is necessary for: A.) Bone and teeth formation B.) Integrity of skin and mucous membrane C.) Blood coagulation D.) Formation of RBC

 ANS: C > Vit K is necessary for blood clotting. Prolonged deficiency of this vitamin leads to bleeding

 65.) The following are signs and symptoms of dehydration EXCEPT: A.) Weight loss B.) Decreased urine output C.) Elevated body temperature D.) Elevated BP

 ANS: D > Elevated BP is not a sign of dehydration. A,B,C are signs and symptoms of dehydration.

 66.) The client is experiencing hypokalemia. Which of the following should be included in his diet? A.) Banana B.) Milk C.) Cheese D.) Fish

 ANS: A > Hypokalemia is low serum potassium level. Providing potassium-rich foods like banana and other fresh fruits is effective nursing intervention for this condition

 67.) During insertion of NGT, which position is best assumed by the client? A.) Low-Fowlers B.) Semi-Fowlers C.) High-Fowlers D.) Lateral

 ANS: C > During insertion of NGT, the patient is best placed in high-Fowlers position with neck hyperextended until the tube is in the oropharynx. Once the NGT is in the oropharynx, the client is instructed to flex the neck and swallow, as the tube is advanced.

 68.) The length of NGT to be inserted is correctly measured; A.) From the tip of the nose to the umbilicus B.) From the tip of the nose to the xiphoid process C.) From the tip of the nose to the earlobe to the umbilicus D.) From the tip of the nose to the earlobe to the xiphoid process.

 ANS: D > The length of NGT to be inserted is measured from the tip of the nose, to the earlobe, to the xiphoid process (N-E-X) which is approximately 50cm

69.) When inserting NGT, the neck should: A.) Flexed B.) Hyperextend C.) Tilted to the left D.) In neutral position

 ANS: B > When inserting NGT, the neck is initially hyperextended

 70.) The most accurate method of assessing method of placement of NGT is: A.) Aspiration B.) Testing the pH of gastric aspiration C.) X-ray study D.) Introduction of air into NGT and auscultate at the epigastric area.

 ANS: C > The most accurate method of assessing placement of NGT is through X-ray.

 71.) Which of the following is inappropriate nursing action when administering NGT feeding? A.) Assist the client in Fowlers position B.) Introduce feeding slowly C.) Place the feeding 24 inches above the point of insertion of NGT D.) Instill 60mls of water into the NGT after feeding

 ANS: C > During NGT feeding, the height of the feeding is 12 inches above the point of NGT insertion, not 24 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.

72.) The primary purpose of gastrostomy is: A.) For feeding B.) For drainage C.) To prevent flatulence D.) To prevent aspiration of gastric reflex

 ANS: A > The primary purpose of gastrostomy is for feeding

 73.) The most important nursing action before gastrostomy feeding is: A.) Check VS B.) Assess for patency of the tube C.) Measure residual feeding D.) Check for placement of the tube

 ANS: B > The most important nursing action before gastrostomy feeding is to assess for patency of the tube. This is done by instilling 15-30 mls of water into the tube.

 74.) The primary advantage of gastrostomy feeding is: A.) It ensures adequate nutrition B.) It prevents aspiration C.) It maintains integrity of gastro-esophageal sphincter D.) It minimizes fluid-electrolyte imbalances

 ANS: C > The primary advantage of gastrostomy feeding is, it maintains the integrity of gastroesophageal sphincter ( cardiac sphincter) of the stomach

75.) Vit B3 (Niacin) deficiency leads to: A.) Pellagra B.) Beriberi C.) Scurvy D.) Rickets

 ANS: A > Vitamin B3 (Niacin) deficiency leads to pellagra

76.) Constipation is best described as: A.) Irregular passage of stool B.) Passage of stool every other day C.) Passage of hard, dry stool D.) Seepage of liquid feces

 ANS: C > Constipation is passage of hard, dry stool

 77.) The accumulation of hardened, putty-like fecal mass at the rectum is A.) Obstipation B.) Constipation C.) Tympanities D.) Fecal impaction

 ANS: D > Fecal impaction is the accumulation of hardened, putty-like fecal mass at the rectum

 78.) The following are appropriate nursing measures to relieve constipation EXCEPT: A.) Include fruits and vegetables B.) Have adequate activity and exercise C.) Take laxatives at regular basis D.) Answer immediately to the urge to defecate

 ANS: C > Regular use of laxative is inappropriate nursing measures to relieve constipation

 79.) Castor oil acts as a laxative by: A.) Providing chemical stimulation of the intestinal mucosa B.) Softening the stool C.) Increasing the bulk of the stool D.) Lubricating the stool

 ANS: A > Castor oil provides chemical stimulation to the intestinal mucosa, to increase peristalsis and promote defecation

 80.) Which of the following foods should be avoided by the client prevent flatulence? A.) Fruit juice B.) Cabbage C.) Meat D.) Fish

 ANS: B > To prevent flatulence, avoid gas-forming foods like cabbage

 81.) Which of the following antidiarrheal medications absorb gas or toxic substances from the bowel?

 ANS: B > Absorbent anti-diarrheal medications absorb gas or toxic substances from the bowel

 82.) The most common-side effect of overuse of laxatives is: A.) Diarrhea B.) Nausea and vomiting C.) Constipation D.) Flatulence

 ANS: C > The most common side-effect of overuse of laxative is rebound constipation

 83.) Which of the following should be included in the diet of the patient with diarrhea? A.) Banana B.) Papaya C.) Pineapple D.) Avocado

 Ans: A > Banana should be included in the diet of the client with diarrhea. It is rich in potassium and it replaces potassium losses due to diarrhea

 84.) Which of the following fluids may be given to a client with diarrhea? A.) Milk B.) Coffee C.) Tea D.) Gatorade

 ANS: D > Gatorade may be given to a client with diarrhea because it is rich in potassium

 85.) Which of the following laxative increases the bulk of the stool? A.) Colace B.) Metamucil D.) Dulcolax D.) Duphalac

 ANS: B > Metamucil increases bulk of the stool and it provides adequate mechanical stimulation for peristalsis

 86.) The following are appropriate nursing measures to relieve diarrhea EXCEPT: A.) Provide high-fiber diet B.) Promote rest C.) Include banana in the diet D.) Avoid fatty or fried food

 ANS: A > High fiber die stimulates peristalsis and therefore inappropriate for a client with diarrhea

 87.) The following are solutions used as nonretention enema EXCEPT: A.) Tap water B.) Carminative enema C.) Normal Saline Solution D.) Fleet Enema

 ANS: B > Carminative enema is used for retention enema. A,C, and D are solutions used as nonretention enema

88.) The medication that relieves flatulence is: A.) Imodium (Loperamide) B.) Plasil (Metochlopramide) C.) Prostigmin (Neostigmine) D.) Colace ( Na Docussate)

 ANS: C > Prostigmin is cholinergic, so it stimulates peristalsis. It is used to relieve flatulence

 89.) The best position of the adult client during enema administration is: A.) Left lateral B.) Supine C.) Right lateral D.) Semi-Fowlers

 ANS: A > Left lateral position is the best position for the adult client receiving enema. This position facilitates the flow of the solution into the colon by gravity

 90.) Which of the following is inappropriate nursing action during rectal tube insertion to relieve flatulence? A.) Insert rectal tube for 3-4 inches B.) Use rectal tube size Fr.22-30 C.) Keep rectal tube in place for 45 minutes D.) Insert well-lubricated rectal tube in rotating motion

 ANS: C > Keeping the rectal tube in place for 45 minutes is inappropriate. Beyond 30 minutes rectal tube causes irritation of the mucous membrane in the rectal area.

 91.) The following are correct nursing actions when administering enema EXCEPT: A.) Provide privacy B.) Introduce solution slowly C.) Alternate NSS with tap water and soap suds D.) Increase the flow rate of the enema solution if abdominal cramps occur

 ANS: D > Increasing flow rate of enema solution if abdominal cramps occur is inappropriate nursing action. Temporarily stop flow of solution if abdominal cramps occur, until peristalsis relaxes.

92.) The functional unit of the kidneys is the: A.) Glomerulus B.) Bowmans capsule C.) Nephron D.) Tubules

 ANS: C > The nephron is the unit of the kidney

93.) Which of the following initiates voiding? A.) Valsalva maneuver B.) Increased intraabdominal pressure C.) Sympathetic response stimulation D.) Parasympathetic response stimulation

 ANS: D > The PNS promotes contraction of the bladder and promotes relaxation of urethral sphincter. Therefore, it initiates voiding.

 94.) The following are normal characteristics of urine EXCEPT: A.) Appears clear B.) pH= 3.5 C.) Sp.Gr=1.020 D.) Amber

 ANS: B > Urine pH of 3.5 if too low. This indicates acidosis. The normal pH of urine is slightly acidic, an average of 6

95.) Frequent scanty urination is: A.) Urgency B.) hesitancy C.) Pollakuria D.) Polyuria

 ANS: C > Pollakuria is frequent scanty urination

 96.) The volume of urine in the bladder that triggers the urge of an adult patient to void is: A.) 50-100mls B.) 100-200 mls C.) 250-450 mls D.) 500-600 mls

 ANS: C > 250-450 mls of urine in the bladder makes an adult client feel the urge to void

 97.) Which of the following is not as assessment finding in urinary retention? A.) Flat sound over the suprapubic area on percussion B.) Smooth, firm ovoid mass at the suprapubic area C.) Protrusion arising out the pelvis D.) Frequent passage of small amount of urine

 ANS: A > Flat sound over the suprapubic area on percussion does not indicate bladder distention. Accumulation of urine in the bladder will produce dull sound

 98.) Which of the following is most effective nursing measure to relieve urinary retention? A.) Allow the patient to listen to the sound of running water B.) Dangle fingers in warm water C.) Provide privacy D.) Pour warm water over perineum

 ANS: C > providing privacy is the most effective nursing measure to relieve urinary retention.

 99.) The best position for female during urinary catheterization is: A.) Supine B.) Dorsal recumbent C.) Lateral D.) Semi-Fowlers

 ANS: B > Dorsal recumbent position is the best position during urethral catheter insertion in a female client.

100.) The female urethral meatus is located: A.) Above the clitoris B.) Below the vaginal C.) Between the clitoris and vaginal orifice D.) Between the vaginal orifice and anus

 ANS: C > The female urethral meatus is located between the clitoris and vaginal orifice