Name: Score:
20 Multiple choice questions
Term 1 of 20
During a physical assessment, the nurse closes and door and provides drape to promote
privacy. The nurse is performing her role as a/an:
A. Advocate
B. Communicator
C. Change agent
D. Caregiver
B. Nasal packing
A rectal temperature is usually recommended whenever an oral temperature is
contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and
those who have history of seizures, etc.). However, a rectal temperature is
contraindicated in patients having rectal disease, rectal surgery or diarrhea)
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.
D. Advanced beginner
A- Novice is governed by rules and usually inflexible. B- Expert nurses have intuitive
grasp on the situation dealt. C- Competent nurses are planning nursing care consciously.
D- Advanced beginners demonstrate acceptable performance.
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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Term 2 of 20
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30
breaths per minute and documents that Jake is tachypneic. The nurse understands that
tachypnea means:
A. Pulse rate greater than 100 beats per minute
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds
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.
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.
B. Instill the medication directly into the tympanic membrane
During the application of medication it is inappropriate to instill the medication directly
into the tympanic membrane. The right thing to do is instill the medication along the
lateral wall of the auditory canal.
C. Respiratory rate greater than 20 breaths per minute
A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure
of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is
tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.
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Term 3 of 20
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
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.
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.
D. 0 degree
The patient should be positioned with the head of the bed completely flattened to
perform an abdominal examination. If the head of the bed is elevated, the abdominal
muscles and organs can be bunched up, altering the findings.
B. Activity
According to Maslow, activity is one of the man's most basic physiologic needs, along
with oxygen, shelter, food, water, thirst, sleep and temperature maintenance.
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