FOUNDATION OF PROFESSIONAL NURSING PRACTICE188
Contents ANSWER KEY - FOUNDATION OF PROFESSIONAL
NURSING PRACTICE I: FOUNDATION OF NURSING NURSING PRACTICE..................................................199
PRACTICE..........................................................................4 COMMUNITY HEALTH NURSING AND CARE OF THE
NURSING PRACTICE II.....................................................15 MOTHER AND CHILD....................................................200
NURSING PRACTICE III....................................................26 ANSWER KEY: COMMUNITY HEALTH NURSING AND
CARE OF THE MOTHER AND CHILD..........................211
NURSING PRACTICE IV....................................................36
Comprehensive Exam 1................................................213
NURSING PRACTICE V.....................................................46
CARE OF CLIENTS WITH PHYSIOLOGIC AND
TEST I - Foundation of Professional Nursing Practice ....56
PSYCHOSOCIAL ALTERATIONS......................................222
Answers and Rationale – Foundation of Professional
ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC
Nursing Practice .........................................................66
AND PSYCHOSOCIAL ALTERATIONS .........................234
TEST II - Community Health Nursing and Care of the
Nursing Practice Test V ................................................235
Mother and Child ...........................................................74
Nursing Practice Test V ................................................245
Answers and Rationale – Community Health Nursing
and Care of the Mother and Child .............................84 TEST I - Foundation of Professional Nursing Practice .. 255
TEST III - Care of Clients with Physiologic and Answers and Rationale – Foundation of Professional
Psychosocial Alterations ................................................91 Nursing Practice .......................................................265
Answers and Rationale – Care of Clients with TEST II - Community Health Nursing and Care of the
Physiologic and Psychosocial Alterations ................102 Mother and Child.........................................................273
TEST IV - Care of Clients with Physiologic and Answers and Rationale – Community Health Nursing
Psychosocial Alterations ..............................................111 and Care of the Mother and Child ...........................283
Answers and Rationale – Care of Clients with TEST III - Care of Clients with Physiologic and
Physiologic and Psychosocial Alterations ................122 Psychosocial Alterations ..............................................290
TEST V - Care of Clients with Physiologic and Psychosocial Answers and Rationale – Care of Clients with
Alterations....................................................................133 Physiologic and Psychosocial Alterations ................301
Answers and Rationale – Care of Clients with TEST IV - Care of Clients with Physiologic and
Physiologic and Psychosocial Alterations ................144 Psychosocial Alterations ..............................................310
PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................321
ANSWERS AND RATIONALE – FOUNDATION OF
NURSING ..................................................................158 TEST V - Care of Clients with Physiologic and Psychosocial
Alterations....................................................................332
PRACTICE TEST II Maternal and Child Health...............162
Answers and Rationale – Care of Clients with
ANSWERS AND RATIONALE – MATERNAL AND CHILD
Physiologic and Psychosocial Alterations ................343
HEALTH.....................................................................167
PART III.........................................................................352
MEDICAL SURGICAL NURSING .....................................173
PRACTICE TEST I FOUNDATION OF NURSING ..............352
ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING ..................................................................178 ANSWERS AND RATIONALE – FOUNDATION OF
NURSING ..................................................................357
PSYCHIATRIC NURSING ................................................180
PRACTICE TEST II Maternal and Child Health...............361
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING
.................................................................................185
, ANSWERS AND RATIONALE – MATERNAL AND CHILD MEDICAL SURGICAL NURSING Part 1...........................475
HEALTH.....................................................................366 ANSWERS and RATIONALES for MEDICAL SURGICAL
MEDICAL SURGICAL NURSING .....................................372 NURSING Part 1........................................................479
ANSWERS AND RATIONALE – MEDICAL SURGICAL MEDICAL SURGICAL NURSING Part 2...........................481
NURSING ..................................................................377 MEDICAL SURGICAL NURSING Part 2.......................485
PSYCHIATRIC NURSING ................................................379 ANSWERS and RATIONALES for MEDICAL SURGICAL
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING NURSING Part 2........................................................489
.................................................................................384 MEDICAL SURGICAL NURSING Part 3...........................491
FUNDAMENTALS OF NURSING PART 1 ........................387 ANSWERS and RATIONALES for MEDICAL SURGICAL
FUNDAMENTALS OF NURSING PART 2 ........................392 NURSING Part 3........................................................495
ANSWERS and RATIONALES for FUNDAMENTALS OF PSYCHIATRIC NURSING Part 1......................................497
NURSING PART 2......................................................397 ANSWERS and RATIONALES for PSYCHIATRIC NURSING
FUNDAMENTALS OF NURSING PART 3 ........................401 Part 1........................................................................502
ANSWERS and RATIONALES for FUNDAMENTALS OF PSYCHIATRIC NURSING Part 2......................................504
NURSING PART 3......................................................405 ANSWERS and RATIONALES for PSYCHIATRIC NURSING
MATERNITY NURSING Part 1........................................409 Part 2........................................................................509
ANSWERS and RATIONALES for MATERNITY NURSING PSYCHIATRIC NURSING Part 3......................................512
Part 1........................................................................418 ANSWERS and RATIONALES for PSYCHIATRIC NURSING
MATERNITY NURSING Part 2........................................428 Part 3........................................................................516
Answer for maternity part 2 ....................................433 PROFESSIONAL ADJUSTMENT......................................519
PEDIATRIC NURSING ....................................................434 LEADERSHIP and MANAGEMENT.................................522
ANSWERS and RATIONALES for PEDIATRIC NURSING NURSING RESEARCH Part 1..........................................532
.................................................................................439 NURSING RESEARCH Part 2..........................................542
COMMUNITY HEALTH NURSING Part 1........................444 Nursing Research Suggested Answer Key ................546
COMMUNITY HEALTH NURSING Part 2........................454
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2
, 5. Benner’s “Proficient” nurse level is different
from the other levels in nursing expertise in the
NURSING PRACTICE I: FOUNDATION OF NURSING context of having:
PRACTICE a. the ability to organize and plan activities
b. having attained an advanced level of
SITUATION: Nursing is a profession. The nurse should education
have a background on the theories and foundation of c. a holistic understanding and perception
nursing as it influenced what is nursing today. of the client
d. intuitive and analytic ability in new
1. Nursing is the protection, promotion and situations
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering SITUATION: The nurse has been asked to administer an
through the diagnosis and treatment of human injection via Z TRACK technique. Questions 6 to 10 refer
response and advocacy in the care of the to this.
individuals, families, communities and the
population. This is the most accepted definition 6. The nurse prepares an IM injection for an adult
of nursing as defined by the: client using the Z track technique. 4 ml of
a. PNA medication is to be administered to the client.
b. ANA Which of the following site will you choose?
c. Nightingale a. Deltoid
d. Henderson b. Rectus femoris
c. Ventrogluteal
2. Advancement in Nursing leads to the d. Vastus lateralis
development of the Expanded Career Roles.
Which of the following is NOT an expanded 7. In infants 1 year old and below, which of the
career role for nurses? following is the site of choice for intramuscular
a. Nurse practitioner Injection?
b. Nurse Researcher a. Deltoid
c. Clinical nurse specialist b. Rectus femoris
d. Nurse anaesthesiologist c. Ventrogluteal
d. Vastus lateralis
3. The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible 8. In order to decrease discomfort in Z track
for the maintenance of the quality of nursing in administration, which of the following is
the country. Powers and duties of the board of applicable?
nursing are the following, EXCEPT: a. Pierce the skin quickly and smoothly at
a. Issue, suspend, revoke certificates of a 90 degree angle
registration b. Inject the medication steadily at around
b. Issue subpoena duces tecum, ad 10 minutes per millilitre
testificandum c. Pull back the plunger and aspirate for 1
c. Open and close colleges of nursing minute to make sure that the needle did
d. Supervise and regulate the practice of not hit a blood vessel
nursing d. Pierce the skin slowly and carefully at a
90 degree angle
4. A nursing student or a beginning staff nurse who
has not yet experienced enough real situations 9. After injection using the Z track technique, the
to make judgments about them is in what stage nurse should know that she needs to wait for a
of Nursing Expertise? few seconds before withdrawing the needle and
a. Novice this is to allow the medication to disperse into
b. Newbie the muscle tissue, thus decreasing the client’s
c. Advanced Beginner discomfort. How many seconds should the nurse
d. Competent wait before withdrawing the needle?
a. 2 seconds
4
, 5
b. 5 seconds that the patient smokes and drinks coffee. When
c. 10 seconds taking the blood pressure of a client who
d. 15 seconds recently smoked or drank coffee, how long
should the nurse wait before taking the client’s
10. The rationale in using the Z track technique in an blood pressure for accurate reading?
intramuscular injection is: a. 15 minutes
a. It decreases the leakage of discolouring b. 30 minutes
and irritating medication into the c. 1 hour
subcutaneous tissues d. 5 minutes
b. It will allow a faster absorption of the
medication 15. While the client has pulse oximeter on his
c. The Z track technique prevent irritation fingertip, you notice that the sunlight is shining
of the muscle on the area where the oximeter is. Your action
d. It is much more convenient for the nurse will be to:
a. Set and turn on the alarm of the
SITUATION: A Client was rushed to the emergency room oximeter
and you are his attending nurse. You are performing a b. Do nothing since there is no identified
vital sign assessment. problem
c. Cover the fingertip sensor with a towel
11. All of the following are correct methods in or bedsheet
assessment of the blood pressure EXCEPT: d. Change the location of the sensor every
a. Take the blood pressure reading on both four hours
arms for comparison
b. Listen to and identify the phases of 16. The nurse finds it necessary to recheck the blood
Korotkoff’s sound pressure reading. In case of such re assessment,
c. Pump the cuff to around 50 mmHg the nurse should wait for a period of:
above the point where the pulse is a. 15 seconds
obliterated b. 1 to 2 minutes
d. Observe procedures for infection control c. 30 minutes
d. 15 minutes
12. You attached a pulse oximeter to the client. You
know that the purpose is to: 17. If the arm is said to be elevated when taking the
a. Determine if the client’s hemoglobin blood pressure, it will create a:
level is low and if he needs blood a. False high reading
transfusion b. False low reading
b. Check level of client’s tissue perfusion c. True false reading
c. Measure the efficacy of the client’s anti- d. Indeterminate
hypertensive medications
d. Detect oxygen saturation of arterial 18. You are to assessed the temperature of the
blood before symptoms of hypoxemia client the next morning and found out that he
develops ate ice cream. How many minutes should you
wait before assessing the client’s oral
13. After a few hours in the Emergency Room, The temperature?
client is admitted to the ward with an order of a. 10 minutes
hourly monitoring of blood pressure. The nurse b. 20 minutes
finds that the cuff is too narrow and this will c. 30 minutes
cause the blood pressure reading to be: d. 15 minutes
a. inconsistent
b. low systolic and high diastolic 19. When auscultating the client’s blood pressure
c. higher than what the reading should be the nurse hears the following: From 150 mmHg
d. lower than what the reading should be to 130 mmHg: Silence, Then: a thumping sound
continuing down to 100 mmHg; muffled sound
14. Through the client’s health history, you gather continuing down to 80 mmHg and then silence.