Exam (Elaborations) Comprehensive Nursing Review By R. C. Reña

COMPREHENSIVE NURSING REVIEW By R. C. REÑA COMPREHENSIVE NURSING REVIEW by R. C. REÑA 2021 COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 2 NURSING LICENSURE EXAMINATIONS In NP1, Please FOCUS on the following: 1. Types of leadership: Autocratic, Laissez faire, Democratic, transformational, transactional etc. etc. 2. Pattern of Nursing care: Primary nursing, case nursing, functional, team etc. 3. Expanded Nursing role: Nurse anesthetist, Nurse practitioner, Nurse researcher etc. etc. 4. Levels of prevention by Leavell and Clark. Remember that crisis is always secondary. 5. 3 way bottle system: simply reconnect the tube, continuous bubble is a sign of leakage, no bubbling is obstruction [in the waterseal] and you should palpate the surrounding area for subcutaneous emphysema 6. Care of clients with tracheostomy and suctioning a tracheostomy tube [sterile technique] know the functions of the cuff, obturator and the tie. care of clients with pooling of secretions. Postural drainage: do this before meals, the positioning depending on the location of secretion, POPEVICO [arrangement] that is positioning, percussing, vibrating and coughing etc. study suctioning. 7. The independent and the dependent variable in research 8. Know your PURE and APPLIED as well as EXPERIMENTAL and NON-EXPERIMENTAL also your QUANTITATIVE and QUALITATIVE designs 9. IV fluid tonicity: D5LR is hypertonic while LR is isotonic 10. Complication of IV and its intervention such as FLUID OVERLOAD, PHLEBITIS, INFILTRATION. 11. Blood transfusion 12. Complication of immobility: DECUBITUS ULCER, HYPO PNEUMONIA, ATELECTASIS, DEEP VEIN THROMBOSIS 13. The VIRTUE ETHICS and ETHICS: Justice, fortitude, prudence, temperance, character, double effect, paternalism... etc etc and the Patient's bill of right. 15. Teaching and learning steps: Man initially needs information and MOTIVATION is needed for adherence to teaching. First step in teaching is to ASSESS LEARNING NEEDS before planning what to teach. 16. SAFETY: Causes of injuries according to age eg: elderly = falls, infant = suffocation and aspiration, adolescence = suicide and homicide. Intervention in an elderly client who falls frequently = keep the bed at the lowest possible position. etc. 18. BON RESOLUTION 220 [CODE OF ETHICS] RA 9173 AND 7164 [COMPARE AND CONTRAST] and the CONTINUING PROFESSIONAL EDUCATION. [To enhance knowledge with regard to specific field of interest] NP2 1. Stages of labor. The first stage up to the fourth stage and the LATENT ACTIVE AND TRANSITION of the first stage. study the intervention in all stages. Read pilleteri for this. 2. The menstrual cycle, what glands secret what hormones. The MENSTRUAL, PROLIFERATIVE, SECRETORY and ISCHEMIC phase. what hormone is at peak during what stage. etc. etc. 3. Causes of bleeding during pregnancy: Ectopic, abruptio and previa plus their nursing intervention. 4. Endometriosis and Endometritis. 5. IMCI : Pneumonia, Diarrhea and Dengue especially the breathing cut off [Eg. 60 for under 2 months], Acute/Chronic cutoff [Acute diarrhea and ear infection under 14 days]. The interventions for CHILD A, B and C. COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 3 6. COMMUNITY HEALTH NURSING PROCESS: Assessment, Planning, Implementation and Evaluation. refer to the DOH book please read this one. 7. Managerial principles. PODC. Types of budgets. Direct, indirect, cash, capital, operational budgets. 8. Read pilleteri for : Characteristic of a toddler and preschool [ eg : asking too many questions, negativistic for toddler. Preschool = associative, imaginary, see the world on his own point of view, superego development etc.] 9. POISONING: Lead, aspirin, etc. etc. this is the common cause of accident among toddlers. 10. Leukemia, Anemia and Sickle cell anemia, chemotherapy for pediatric clients. 11. NEWBORN SCREENING 12. Amniocentesis = VOID, Ultrasonography = DRINK, Leopolds Maneuver = VOID, Paracentesis = VOID 13. Changes during pregnancy [eg: Leukorrhea, braxton hicks, anemia] and what changes occurs early or late. Refer to Pillitteri 14. Pregnancy and nutrition: Balanced diet + 300 cal for pregnant. +500 cal for breastfeeding 15. PIH and MAGNESIUM SULFATE. [cns down, rr down, u/o down ] priority : RR NP3 AND NP4 1. Burns, Classification of Burns and Nursing Diagnosis for Burns, Drug use in burns [Silver Sulfadiazine], Electrolyte changes in burn [Hyperkalemia, Hyponatermia]. The WHO Pain ladder scale, Pain medications especially Demerol, Morphine and Fentanyl. Remember that PAIN is the hardest part for the nurse in caring for a burned victim. Burn wounds heal by secondary intention. 2. Nursing diagnosis after anesthesia : RISK FOR INFECTION or INEFFECTIVE AIR CLEARANCE. 3. PACU MONITORING = Q15 , SURGICAL FLOOR MONITORING = Q30 4. Pancreatitis, Cholecystitis, Hepatitis. Morphine causes spasms in the sphincter of oddi. Hepa B is caused by blood exchange. Hepa A is oro-fecal. both have vaccines either passive or active but if already exposed, Give PASSIVE. 5. Diabetes mellitus, Metformin and contrast medium [stop metformin due to renal toxicity], Insulin rotation and administration, diabetes r/t footcare. Avoid wearing canvass shoes, check for the sensation, do not go outside without slippers. PERIPHERAL NEUROPATHY. OHA drugs. 6. Electrolytes abnormality especially HYPOCALCEMIA and HYPER/HYPOKALEMIA. The ECG changes in potassium alteration, intervention and causes. 7. Myocardial infarction : ECG changes as well as nursing intervention. Causes and risk factors. Refer to BRUNNER. 8. Pharmacologic and Nonpharmacologic pain relief : Guided imagery, Biofeedback, Intrathecal [into the spinal canal directly to mix with csf] and epidural [ into the epidural space ] pain management. side effects of morphine in elderly = PRURITUS and ALLERGIC RXN and RR DEPRESSION. Reason for intrathecal admininstration = prevent Blood brain barrier. 9. BREAST and CERVICAL cancer. Assessment, Diagnosis and Treatment. 10. Management for a client with COLOSTOMY. The irrigation, diet and body image alteration as well as perioperative management of a client undergoing your ABDOMINAL PERINEAL RESECTION with permanent colostomy. Drugs given before APR such as neomycin and sulfasuzidine, Diet before APR [low fiber], normal color of the stoma just after APR [slightly bleeding, red and protruding] 11. Insulin administration, types and rotation. Refer to brunner. 1 inch away from each injection site, administer at room temp not cold to prevent lipodystrophy, abdomen has the fastest absorption. etc. etc. 12. Interventions during hypo- and hyperglycemia COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 4 13. Care of clients with hyper- and hypothyroidism, study TAPAZOLE/METHIMAZOLE and LUGOL'S SOLUTION, PTU. Care of clients after thyroidectomy: Monitor for hypocalcemia teach clients HEAD SUPPORT by putting hands at the back of the neck before trying to move the head. 14. Tuberculosis and Leprosy, its early / late sign and symptoms. 15. Acute and Chronic renal failure. Causes [Post/pre/intra] and hemodialysis. 16. AGN, Rheumathoid and Ostearthritis, Bell's Palsy and Trigeminal neuralgia 17. Study radiation and chemotherapy and their usual side effects [Skin burn, redness, do not wet radiation mark]. Mammography, BSE, TSE, DRE, Prostate and Colon cancer, Changes that occurs during elderly, Bladder, Colon and Cervical cancer Diagnostic examination/CEA, Proctosigmoidoscopy, Biopsy, Pap smear. 18. Laryngeal cancer and tracheostomy care. [refer to Kozier for tracheostomy care] NP5 1. In your Test V study the following: Anxiety and anxiety disorders, The level of anxiety and your anxiolytics, Schizophrenia: Paranoid type and Catatonic type and your nursing interventions for these clients as well as your priority nursing diagnosis. 2. Depression and your antidepressants, Mania, Personality disorders especially your Antisocial, Borderline and Paranoid. The defense mechanism use for different types of disorders and the priority NURSING DIAGNOSIS for each psychiatric disorders, Antipsychotic drugs its side effects and nursing intervention for each side effects. 3. Electroconvulsive therapy, Thought process disturbance manifestation such as Clang Association, Pressured speech, Thought blocking, Word salad, perseveration etc. etc. Alteration in perception and thought like hallucination and delusion. Types of delusions eg. religious and persecutory. Activities and diet as well as nursing diagnosis for a client with Mania, Depressed and Alzheimer’s/Dementia patient. 4. Eating disorders and the treatments of choice [Behavior therapy for Anorexia, Psychotherapy for the Personality Disorders, Cognitive therapy for depression ] Always answer "STAY WITH THE CLIENT" especially if the question is about anxiety disorders and panic attacks. Always choose an option that will encourage verbalization of feelings, never answer an option with the word WHY. 5. Study your counter transference and your transference, Glaucoma, Cataract and crutch/cane walking. The principles of body mechanics, cranial nerve functioning and how to assess them as well as their disturbances especially Bells and Trigeminal Neuralgia. Meniere's disease, Delirum, Dementia, CVA/Stroke pathophysiology and Factors. 6. Psychotherapy : Behavior therapy - aversion, operant conditioning [positive reinforcement] systematic desensitization. Cognitive therapy is the PSYCHOTHERAPY of choice for depression. Study therapeutic milieu - general pt management, environmental manipulation, uses democratic leadership to test new patterns of behavior. Community meeting is the heart of milieu therapy. Pharmacotherapy: Drug classification and side effects of ANTIPSYCHOTIC, ANXIOLYTICS, ANTIMANIC [Tegretrol, Lithium, Depakene] 7. Transfer of clients from BED to CHAIR as well as MOVING CLIENT UP IN BED [READ KOZIER] 8. Supporting the client in: SUPINE [eg. prevent neck hyperextension by putting pillow], FOWLERS [prevent posterior curvature of the spine], DORSAL RECUMBENT [prevent hyperextension of the knee] AND SIDELYING position [Prevent lateral flexion of the sternocleidomastoid] 9. Equipments for immobility : Trochanter roll/sandbags - prevent external rotation of the hips. Pillow to support back, head, arms and shoulders. Footboard to prevent footdrop. Trapeze bar to move the client up in bed. Knee gatch or pillow - to slightly flex the clients knee. 10. INTRODUCE CHANGE GRADUALLY - Study methods of implementing change such as FORCE FIELD ANALYSIS - THE DRIVING AND THE RESTRAINING FORCES, FOCUS - FIND ORGANIZE CLARIFY UNDERSTAND SOLUTION. THE PDSA CYCLE - PLAN DO STUDY ACT. COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 5 THE 6 TECHNICAL TIPS FOR THE BOARD EXAMINATION 1. Accept the fact that you can never know everything. Therefore, once you see an unfamiliar question that was never been taught, use your test taking strategies. 2. If you are in Test I, II, III, and IV and you are being asked to prioritize, Use ABC first and then Maslow's Hierarchy of needs. 3. The use of your nursing process is heralded by the word: "The Nurse Would or The nurse's initial action" Remember to Assess first before intervening. If the situation and the question already assessed the patient, then proceed with the next step. 4. Encircle your modifiers. Some people make mistakes because of failure to see the word, "EXCEPT" or "NOT" or "INAPPROPRIATE", etc. The magic words… 5. Use your questionnaires as your scratch. You can write anything on that paper. If you will skip a number, place an asterisk or encircle the number. 6. DO NOT USE BLUNT PENCIL. Always use a sharp one and shade lightly. A sharpened pencil will give a very dark shade even if you will shade it lightly. Use the sides of the pencil not the tip. Use MONGOL NUMBER 2 ONLY. Some brands especially those made in china pencils are substandard. The machine will check the lead. If you are INCONSISTENT with your shading like an altering dark and light shades, you will FAIL the boards because of technicalities. Care has been taken to confirm the accuracy of the information presented. Nevertheless, it is difficult to ensure that all the information presented is entirely accurate for all circumstances, and the author cannot accept any responsibility for any error or omission. The author makes no warranty, expressed or implied, with respect to this work, and disclaims any liability, loss, or damage as a consequence, directly or indirectly, of the use and application of any of the contents of this work References: Adele Pillitteri. MATERNAL & CHILD HEALTH NURSING: Care of the Childbearing & Childrearing Family. 2005 COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 6 PRAYERS TO ST. JOSEPH OF CUPERTINO FOR SUCCESS IN EXAMINATIONS First Prayer O Great St. Joseph of Cupertino who while on earth did obtain from God the grace to be asked at your examination only the questions you knew, obtain for me a like favour in the examinations for which I am now preparing. In return I promise to make you known and cause you to be invoked. Through Christ our Lord. St. Joseph of Cupertino, Pray for us. Amen. Second Prayer O St. Joseph of Cupertino who by your prayer obtained from God to be asked at your examination, the only preposition you knew. Grant that I may like you succeed in the Nursing Licensure Examination. In return, I promise to make you known and cause you to be invoked. O St. Joseph of Cupertino pray for me O Holy Ghost enlighten me Our Lady of Good Studies pray for me Sacred Head of Jesus, Seat of divine wisdom, enlighten me. PRAYER TO SAINT JUDE THADDEUS, PATRON OF THE IMPOSSIBLE Most Holy Apostle St. Jude, faithful servant and friend of Jesus, the church honors and invokes you universally as the patron of difficult cases, of things almost despaired of, pray for me. I am so helpless and alone. Intercede to God for me that He brings visible and speedy help where help is almost despaired of. Come to my assistance in this great need that I may receive the consolation and help of heaven in all my necessities, tribulations and sufferings particularly (here make your request) and that I may praise God with you and all the saints forever. I promise, O Blessed St. Jude, to be ever mindful of this great favor granted to me by God and to always honor you as my special and powerful patron and to gratefully encourage devotion to you. Amen. COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 7 PRINCIPLES OF TEST TAKING I. PRINCIPLE OF CONTRADICTION When two options contradict each other, there is a higher chance of one of them being the correct answer. Example: Which physiologic effect should the nurse expect in a client addicted to hallucinogens? A. Dilated pupils B. Constricted pupils C. Bradycardia D. Bradypnea II. PRINCIPLE OF COMMONALITY AND DIFFERENCE Two or more options that has the same essential configuration and thought is unlikely the correct answer. Example: When injecting subcutaneous injection in an obese patient, it should be angled at around: A. 45° B. 90° C. 180° D. Parallel to the skin III. PRINCIPLE OF CENTRAL TENDENCY Correct answers in an all numeric options is most likely located in between the extremes. Example: What is the KVO rate of BT? A. 5 gtts/min B. 10 gtts/min C. 15 gtts/min D. 20 gtts/min IV. PRINCIPLE OF POSITIVE AND NEGATIVE HARMONY A positive question will always ask for a positive answer and so is a negative question. FORMULA: [-] [-] = + Question [+] [+] = + Question [-] [+] = - Question Example: All but one of the following is an Anxiolytic: [+] [-] A. Tranxene B. Miltown C. Atarax D. Parlodel V. PRINCIPLE OF IMPROBABLE EXTREMES Extreme modifiers, such as always, all, never, or only make it more likely that the question is false. Here is a more complete list of EXTREME modifiers. All, every, nothing, none, best, absolutely, always, never, worst, absolutely not, only, nobody, everybody, certainly, invariably, no one, everyone, certainly not. Example: The most effective way in limiting the number of microorganism in the hospital is: A. Using strict aseptic technique in all procedures B. Wearing mask and gown in care of all patients with communicable diseases C. Sterilization of all instruments D. Handwashing VI. PRINCIPLE OF INITIATIVE CRITICAL THINKING 1. Cover the options 2. Read the question carefully 3. Try answering the question without looking at the options 4. Select the option that most closely matches your answer Example: The nurse knew that the normal color of Michiel’s stoma should be: A. Brick Red B. Gray C. Blue D. Pale Pink COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8 VII. PRINCIPLE OF GRAMMATICAL HARMONY Options that do not coincide with the grammatical configuration of the stem is NOT the correct answer. Choices that are grammatically incorrect or contain typographical errors are probably not the correct answer. Example: When planning a care for a client who is pancytopenic, The major goal should be: C.Prevent hemorrhage, infection and decrease oxygenation B. Administering an oral iron preparation C. Preventing Fatigue and fluid overload D. Encouraging a consumption of a neutropenic diet VIII. PRINCIPLE OF UMBRELLA EFFECT A choice that is more inclusive is usually the correct answer. Example: To view a person holistically, the nurse should think of him or her as: A. Physical being who experiences pathology and sociological changes B. Social being who needs the dynamics of group interaction C. Psychological being whose mind influences his or her health status D. Biopsychosocial being who is in constant interaction with the environment IX. Principle of ABC, Maslow’s Hierarchy and Nursing Process When questions require prioritization, these principles should apply. Keywords that indicate the need to prioritize include: BEST VITAL ESSENTIAL PRIMARY FIRST HIGHEST PRIORITY IMMEDIATE INITIAL MOST IMPORTANT NEXT Example: A nurse is reviewing the plan of care for a pregant client with a diagnosis of sickle cell anemia. Which nursing diagnosis, if stated on the plan of care, would the nurse select as receiving the highest priority? A.Anxiety B.Ineffective coping C.Disturbed body image D.Deficient fluid volume Example: When caring for Aida after a chest surgery, your priority would be to maintain: A. Supplementary oxygen B. Chest tube drainage C. Blood replacement D. Ventilation exchange X. Principle of “Tell Me More” In Psychiatric Nursing, Remember to focus on the client’s feeling, concerns, anxieties and fears. This is best summarized by a response that encourages the client’s verbalization of feelings. Example: A mother says to the nurse, “I am afraid that my child might have another seizure” Which response by the nurse is most therapeutic? A. “Why worry about something you cannot control?” B. “Most children will never experience a second seizure” C. “Tell me what frightens you the most about seizures.” D. “Tylenol can prevent another seizure from occuring” XI. Principle of Reappearing Visage A word or phrase that appears in the question and then reappears at one of the 4 choices is the most probable answer. Example: A chronically ill school-age child is most vulnerable to which stressor? A. Mutilation anxiety B. Anticipatory grief C. Anxiety over school absences D. Fear of hospital procedures COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 9 XII. The Drug Technique Most drugs, especially psychotropic medications either act as a CNS Stimulant or a CNS depressant. The strategy revolves in determining which are the Central nervous system excitations and which are the Central nervous system inhibitions. If 3 of the options are all CNS up and 1 is CNS down, pick the CNS down. If 3 of the options are all CNS down and 1 is CNS up, pick the CNS up. Example: The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent? A. Combativeness, sweating, and confusion B. Agitation, hyperactivity, and grandiose ideation C. Suspiciousness, dilated pupils, and increased blood pressure D. Emotionally blunt, lethargy and impaired memory COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 10 CONTENTS FUNDAMENTALS OF NURSING ............…...………12 MATERNITY NURSING …………………….……… 33 PEDIATRIC NURSING………………………..………57 COMMUNITY HEALTH NURSING …………………67 MEDICAL SURGICAL NURSING ………………..… 95 PSYCHIATRIC NURSING ……………………........... 117 PROFESSIONAL ADJUSTMENT …..………………. 141 LEADERSHIP and MANAGEMENT ……………….. 144 NURSING RESEARCH ……………………..………...156 COMPREHENSIVE EXAMINATION ……………….. 173 COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 11 COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 12 FUNDAMENTALS OF NURSING PART 1 1. Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? a. Providing a back massage b. Feeding a client c. Providing hair care d. Providing oral hygiene 2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature? a. Oral b. Axillary c. Radial d. Heat sensitive tape 3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document this findings as: a. Tachypnea b. Hyper pyrexia c. Arrythmia d. Tachycardia 4. Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair? a. Bend at the waist and place arms under the client’s arms and lift b. Face the client, bend knees and place hands on client’s forearm and lift c. Spread his or her feet apart d. Tighten his or her pelvic muscles 5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature? a. Oral b. Axillary c. Arterial line d. Rectal 6. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is: a. Fowler’s position b. Side lying c. Supine d. Trendelenburg 7. A client is hospitalized for the first time, which of the following actions ensure the safety of the client? a. Keep unnecessary furniture out of the way b. Keep the lights on at all time c. Keep side rails up at all time d. Keep all equipment out of view 8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? a. Assessment b. Diagnosis c. Planning d. Implementation 9. It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community a. Assessment b. Nursing Process c. Diagnosis d. Implementation 10. Exchange of gases takes place in which of the following organ? a. Kidney b. Lungs c. Liver d. Heart 11. The Chamber of the heart that receives oxygenated blood from the lungs is the? a. Left atrium COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 13 b. Right atrium c. Left ventricle d. Right ventricle 12. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of food… a. Gallbladder b. Urinary bladder c. Stomach d. Lungs 13. The ability of the body to defend itself against scientific invading agent such as baceria, toxin, viruses and foreign body a. Hormones b. Secretion c. Immunity d. Glands 14. Hormones secreted by Islets of Langerhans a. Progesterone b. Testosterone c. Insulin d. Hemoglobin 15. It is a transparent membrane that focuses the light that enters the eyes to the retina. a. Lens b. Sclera c. Cornea d. Pupils 16. Which of the following is included in Orem’s theory? a. Maintenance of a sufficient intake of air b. Self perception c. Love and belonging d. Physiologic needs 17. Which of the following cluster of data belong to Maslow’s hierarchy of needs a. Love and belonging b. Physiologic needs c. Self actualization d. All of the above 18. This is characterized by severe symptoms relatively of short duration. a. Chronic Illness b. Acute Illness c. Pain d. Syndrome 19. Which of the following is the nurse’s role in the health promotion a. Health risk appraisal b. Teach client to be effective health consumer c. Worksite wellness d. None of the above 20. It is describe as a collection of people who share some attributes of their lives. a. Family b. Illness c. Community d. Nursing 21. Five teaspoon is equivalent to how many milliliters (ml)? a. 30 ml b. 25 ml c. 12 ml d. 75 ml 22. 1800 ml is equal to how many liters? a. 1.8 b. 18000 c. 180 d. 2800 23. Which of the following is the abbreviation of drops? a. Gtt. b. Gtts. c. Dp. d. Dr. COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 14 24. The abbreviation for micro drop is… a. μgtt b. gtt c. mdr d. mgts 25. Which of the following is the meaning of PRN? a. When advice b. Immediately c. When necessary d. Now 26. Which of the following is the appropriate meaning of CBR? a. Cardiac Board Room b. Complete Bathroom c. Complete Bed Rest d. Complete Board Room 27. 1 tsp is equals to how many drops? a. 15 b. 60 c. 10 d. 30 28. 20 cc is equal to how many ml? a. 2 b. 20 c. 2000 d. 20000 29. 1 cup is equal to how many ounces? a. 8 b. 80 c. 800 d. 8000 30. The nurse must verify the client’s identity before administration of medication. Which of the following is the safest way to identify the client? a. Ask the client his name b. Check the client’s identification band c. State the client’s name aloud and have the client repeat it d. Check the room number 31. The nurse prepares to administer buccal medication. The medicine should be placed… a. On the client’s skin b. Between the client’s cheeks and gums c. Under the client’s tongue d. On the client’s conjuctiva 32. The nurse administers cleansing enema. The common position for this procedure is… a. Sims left lateral b. Dorsal Recumbent c. Supine d. Prone 33. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which of the following measures the nurse should do? a. Dissolve the capsule in a glass of water b. Break the capsule and give the content with an applesauce c. Check the availability of a liquid preparation d. Crash the capsule and place it under the tongue 34. Which of the following is the appropriate route of administration for insulin? a. Intramuscular b. Intradermal c. Subcutaneous d. Intravenous 35. The nurse is ordered to administer ampicillin capsule TIP p.o. The nurse shoud give the medication… a. Three times a day orally b. Three times a day after meals c. Two time a day by mouth d. Two times a day before meals 36. Back Care is best describe as: a. Caring for the back by means of massage b. Washing of the back COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 15 c. Application of cold compress at the back d. Application of hot compress at the back 37. It refers to the preparation of the bed with a new set of linens a. Bed bath b. Bed making c. Bed shampoo d. Bed lining 38. Which of the following is the most important purpose of handwashing a. To promote hand circulation b. To prevent the transfer of microorganism c. To avoid touching the client with a dirty hand d. To provide comfort 39. What should be done in order to prevent contaminating of the environment in bed making? a. Avoid funning soiled linens b. Strip all linens at the same time c. Finished both sides at the time d. Embrace soiled linen 40. The most important purpose of cleansing bed bath is: a. To cleanse, refresh and give comfort to the client who must remain in bed b. To expose the necessary parts of the body c. To develop skills in bed bath d. To check the body temperature of the client in bed 41. Which of the following technique involves the sense of sight? a. Inspection b. Palpation c. Percussion d. Auscultation 42. The first techniques used examining the abdomen of a client is: a. Palpation b. Auscultation c. Percussion d. Inspection 43. A technique in physical examination that is use to assess the movement of air through the tracheobronchial tree: a. Palpation b. Auscultation c. Inspection d. Percussion 44. An instrument used for auscultation is: a. Percussion-hammer b. Audiometer c. Stethoscope d. Sphygmomanometer 45. Resonance is best describe as: a. Sounds created by air filled lungs b. Short, high pitch and thudding c. Moderately loud with musical quality d. Drum-like 46. The best position for examining the rectum is: a. Prone b. Sim’s c. Knee-chest d. Lithotomy 47. It refers to the manner of walking a. Gait b. Range of motion c. Flexion and extension d. Hopping 48. The nurse asked the client to read the Snellen chart. Which of the following is tested: a. Optic b. Olfactory c. Oculomotor d. Troclear 49. Another name for knee-chest position is: a. Genu-dorsal COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 16 b. Genu-pectoral c. Lithotomy d. Sim’s 50. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication a. Use a small gauge needle b. Apply ice on the injection site c. Administer at a 45° angle d. Use the Z-track technique ANSWERS for FUNDAMENTALS OF NURSING PART 1 1.d 11.a 21.b 31.b 41.a 2.b 12.c 22.a 32.a 42.d 3.d 13.c 23.b 33.c 43.b 4 b 14.c 24.a 34.c 44.c 5.b 15.c 25.c 35.a 45.a 6.b 16.a 26.c 36.a 46.c 7.c 17.d 27.b 37.b 47.a 8.a 18.b 28.b 38.b 48.a 9.b 19.b 29.a 39.a 49.b 10.b 20.c 30.a 40.a 50.d COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 17 FUNDAMENTALS OF NURSING PART 2 1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be… a. Maintain the patient on strict bed rest at all times b. Maintain the patient in an orthopneic position as needed c. Administer oxygen by Venturi mask at 24%, as needed d. Allow a 1 hour rest period between activities 2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as: a. Tachypnea b. Eupnca c. Orthopnea d. Hyperventilation 3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for: a. Instructing the patient about this diagnostic test b. Writing the order for this test c. Giving the patient breakfast d. All of the above 4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include: a. A ham and Swiss cheese sandwich on whole wheat bread b. Mashed potatoes and broiled chicken c. A tossed salad with oil and vinegar and olives d. Chicken bouillon 5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include: a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. b. Reporting an APTT above 45 seconds to the physician c. Assessing the patient for signs and symptoms of frank and occult bleeding d. All of the above 6. The four main concepts common to nursing that appear in each of the current conceptual models are: a. Person, nursing, environment, medicine b. Person, health, nursing, support systems c. Person, health, psychology, nursing d. Person, environment, health, nursing 7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is: a. Love b. Elimination c. Nutrition d. Oxygen 8. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do? a. Discourage them from making a decision until their grief has eased b. Listen to their concerns and answer their questions honestly c. Encourage them to sign the consent form right away d. Tell them the body will not be available for a wake or funeral 9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do? a. Complain to her fellow nurses b. Wait until she knows more about the unit c. Discuss the problem with her supervisor d. Inform the staff that they must volunteer to rotate 10. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? a. Continuity of patient care promotes efficient, cost-effective nursing care b. Autonomy and authority for planning are best delegated to a nurse who knows the patient well c. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 18 d. The holistic approach