Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 1_Answered correctly with Full rationales.

Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 1_Answered. 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 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 C. Change agent D. Caregiver 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 C. Competent D. Advanced beginner Newborn screening is done to every newborn in the Philippines. This is an example of: A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Rehabilitation One of Nurse Cathy's co-workers is Annie who is flexible in any given situation. Annie is performing her duties well without supervision but still needs more experience and practice to develop a consciously planned nursing care. According to Patricia Benner's category in specialization in nursing, Annie is a/an: A. Novice B. Expert C. Competent D. Advanced beginner The clinical instructor is discussing about the Nursing Process. She mentioned that when a cluster of actual or high-risk diagnosis are present because of a certain situation it is called: A. Wellness nursing diagnosis B. Actual nursing diagnosis C. Syndrome nursing diagnosis D. Risk nursing diagnosis The nurse in charge measures a patient's temperature at 101 degrees F. What is the equivalent centigrade temperature? A. 36.3 degrees C B. 37.95 degrees C C. 40.03 degrees C D. 38.01 degrees C During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? A. That the patient verbalized, "My headache is gone." B. That the patient's barium enema performed 3 days ago was negative C. Patient's NGT was removed 2 hours ago D. Patient's family came for a visit this morning. 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 C. Slow that infusion to 20 ml/hr D. Place a cold towel on the 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 C. Capillary refill greater than 3 seconds and buccal cyanosis D. Hemoglobin of 13 g/dl What is the order of the nursing process? A. Assessing, diagnosing, implementing, evaluating, planning B. Diagnosing, assessing, planning, implementing, evaluating C. Assessing, diagnosing, planning, implementing, evaluating D. Planning, evaluating, diagnosing, assessing, implementing 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 D. Incorporation of both nursing and medical diagnoses in patient care What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? A. Use sterile gloves when obtaining urine B. Open the drainage bag and pour out the urine C. Disconnect the catheter from the tubing and get urine D. Aspirate urine from the tubing port using a sterile syringe 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 Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor 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 C. Gurgles D. Vesicular Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? A. Low blood pressure B. Warm, dry skin C. Decreased serum sodium levels D. Decreased urine output When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? A. 30 degrees B. 90 degrees C. 45 degrees D. 0 degree Which of the following is inappropriate nursing action when administering NGT feeding? A. Place the feeding 20 inches above the point of insertion of NGT B. Introduce the feeding slowly C. Instill 60ml of water into the NGT after feeding D. Assist the patient in fowler's position During application of medication into the ear, which of the following is inappropriate nursing action? A. In an adult, pull the pinna upward B. Instill the medication directly into the tympanic membrane C. Warm the medication at room or body temperature D. Press the tragus of the ear a few times to assist flow of medication into the ear canal Kussmaul's breathing is: A. Shallow breaths interrupted by apnea B. Prolonged gasping inspiration followed by a very short, usually inefficient expiration C. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea 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) C. 4th CN (Trochlear) D. 7th CN (Facial) When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ? A. Thigh B. Liver C. Intestine D. Lung To assess the adequacy of food intake, which of the following assessment parameters is best used? A. Food preferences B. Regularity of meal times C. 3-day diet recall D. Eating style and habits Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: A. 3 months B. 6 months C. 9 months D. 1 year It is the gradual decrease of the body's temperature after death: A. Livor mortis B. Rigor mortis C. Algor mortis D. none of the above Prolonged deficiency of Vitamin B9 leads to: A. Scurvy B. Pellagra C. Megaloblastic anemia D. Pernicious anemia 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 When assessing a patient's level of consciousness, which type of nursing intervention is the nurse performing? A. Independent B. Dependent C. Collaborative D. Professional Which of the following is a nursing diagnosis? A. Hypothermia B. Diabetes Mellitus C. Angina D. Chronic Renal Failure A skin lesion which is fluid-filled, less than 1 cm in size is called: A. Papule B. Vesicle C. Bulla D. Macule S1 is heard best at the: A. 5th left intercostal space along the midclavicular line B. 3rd intercostal space to the left of the midclavicular line C. Second right intercostal space at the sternal border D. Second left intercostal space at the sternal border The correct site at which to verify a radial pulse measurement is the: A. Brachial artery B. Apex of the heart C. Temporal artery D. Inguinal site To promote correct anatomic alignment in a supine patient, the nurse should: A. Place the patient's feet in dorsiflexion B. Place a pillow under the patient's knees C. Hyperextend the patient's neck D. Adduct the patient's shoulder Postural drainage to relieve respiratory congestion should take place: A. Before meals B. After meals C. At the nurse's convenience D. At the patient's convenience 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 C. Nasal catheter D. Partial rebreathing mask The nurse's main priority when caring for a patient with hemiplegia? A. Educating the patient B. Providing a safe environment C. Promoting a positive self-image D. Helping the patient accept the illness A sudden redness of the skin is known as: A. Flush B. Cyanosis C. Jaundice D. Pallor A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action? A. Administer a sedative at bedtime, as ordered by the physician B. Ambulate the patient for 5 minutes before he retires C. Give the patient a glass of warm milk before bedtime D. Close the patient's door from 9pm to 7am 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 C. Injury, error and assault D. Proximal cause, negligence and nurse error Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus? A. Martha Rogers B. Dorothea Orem C. Florence Nightingale D. Sister Callista Roy Which of the following nursing theorists developed a conceptual model based on the belief that all persons strive to achieve self-care? A. Martha Rogers B. Dorothea Orem C. Florence Nightingale D. Sister Callista Roy The average daily amount of urine excreted by an adult is: A. 500 to 600 ml B. 800 to 1,400 ml C. 1,000 to 1,200 ml D. 1,500 to 2,000 ml The nurse should take a rectal temperature of a patient who has: A. His arm in a cast B. Nasal packing C. External hemorrhoids D. Gastrostomy feeding tubes The usual sequence for assessing the bowel is: A. Right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant B. Right lower lobe, right upper lobe, left upper lobe, left lower lobe C. Right hypochondriac, left hypochondriac and umbilical regions D. Rectum, pancreas, stomach and liver 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. Constipation is a common problem for immobilized patients because of: A. Decreased tightening of the anal sphincter B. An increased defecation reflex C. Decreased peristalsis and positional discomfort D. Increased colon motility According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen? A. Safety B. Activity C. Love D. Self esteem - 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. The term gavage indicates: A. Administration of a liquid feeding into the stomach B. Visual examination of the stomach C. Irrigation of the stomach with a solution D. A surgical opening through the abdomen to the stomach Which communication skills is most effective in dealing with covert communication? A. Clarification B. Listening C. Evaluation D. Validation