Nursing practice i � foundation of professional nu

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Nursing practice i � foundation of professional nu

1. Situation - 1Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg subcutaneously.

1. The indication for epinephrine injection for Mrs. Simon is to:

Restore client
Relieve respiratory distress due to bronchial spasm
Reduce anaphylaxis
Relieve hypersensitivity to allergen

2. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg subcutaneously.

1. The indication for epinephrine injection for Mrs. Simon is to:

Relieve hypersensitivity to allergen
Relieve respiratory distress due to bronchial spasm
Reduce anaphylaxis
Restore client�s cardiac rhythm

3. When preparing the epinephrine injection from an ampule, the nurse initially:

Checks expiration date of the medication ampule
Taps the ampule at the top to allow fluid to flow to the base of the ampule
Removes needle cap of syringe and pulls plunger to expel air
Breaks the neck of the ampule with a gauze wrapped around it

4. When preparing the epinephrine injection from an ampule, the nurse initially:

Taps the ampule at the top to allow fluid to flow to the base of the ampule
Breaks the neck of the ampule with a gauze wrapped around it
Removes needle cap of syringe and pulls plunger to expel air
Checks expiration date of the medication ampule

5. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to:

Pinch skin at the injection site and use airlock technique
Pull skin of patient down to administer the drug in a Z track
Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
Inject needle at a 15 degree angle over the stretched skin of the client

6. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to:

Pinch skin at the injection site and use airlock technique
Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
Pull skin of patient down to administer the drug in a Z track
Inject needle at a 15 degree angle over the stretched skin of the client

7. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

Syringe 2 ml and needle gauge 22
Syringe 1-3 ml and needle gauge 25 to 27
Syringe 3-5 ml and needle gauge 21 to 23
Tuberculin syringe 1 ml with needle gauge 26 or 27

8. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

Syringe 3-5 ml and needle gauge 21 to 23
Syringe 1-3 ml and needle gauge 25 to 27
Syringe 2 ml and needle gauge 22
Tuberculin syringe 1 ml with needle gauge 26 or 27

9. The rationale for giving medications through the subcutaneous route is:

There are less pain receptors in this area
Absorption time of the medicine is slower
There are many alternative sites for subcutaneous injection
The medication can be injected while the client is in any position

10. The rationale for giving medications through the subcutaneous route is:

There are many alternative sites for subcutaneous injection
The medication can be injected while the client is in any position
There are less pain receptors in this area
Absorption time of the medicine is slower

11. Situation 2 - The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials.

6. Martha wants to do a study on this topic: 'Effects of massage and meditation on stress and pain'. The type of research that best suits this topic is:

Basic research
Qualitative research
Quantitative research
Applied research

12.

6. Martha wants to do a study on this topic: �Effects of massage and meditation on stress and pain�. The type of research that best suits this topic is:

Qualitative research
Basic research
Applied research
Quantitative research

13. The type of research design that does not manipulate independent variable is:

Non-experimental design
Quantitative design
Quasi-experimental design
Experimental design

14. The type of research design that does not manipulate independent variable is:

Non-experimental design
Quantitative design
Quasi-experimental design
Experimental design

15. This research topic has the potential to contribute to nursing because it seeks to

include new modalities of care
enhance client care
clarify an ambiguous modality of care
resolve a clinical problem

16. This research topic has the potential to contribute to nursing because it seeks to

enhance client care
include new modalities of care
resolve a clinical problem
clarify an ambiguous modality of care

17. Martha does review of related literature for the purpose of

gathering data about what is already known or unknown about the problem
to identify if problem can be replicated
determine statistical treatment of data research
answering the research question

18. Martha does review of related literature for the purpose of

answering the research question
to identify if problem can be replicated
gathering data about what is already known or unknown about the problem
determine statistical treatment of data research

19. Client's rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT:

right of privacy
right to compensation
right not to be harmed
right of self-determination

20. Client�s rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT:

right not to be harmed
right of self-determination
right to compensation
right of privacy

21. Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive secretions in the airway.

Client lying on his right then left side on Trendelenburg position
Client lying flat on his back and then flat on his abdomen
Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
Client lying on his back then flat on his abdomen on Trendelenburg position

22. Part of Nurse Mario�s nursing care plan is to loosen and remove excessivesecretions in the airway.

11. Mario listens to Richard�s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

Client lying flat on his back and then flat on his abdomen
Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
Client lying on his right then left side on Trendelenburg position
Client lying on his back then flat on his abdomen on Trendelenburg position

23. When documenting outcome of Richard's treatment Mario should include the following in his recording EXCEPT:

Amount of fluid intake of client before and after the procedure
Character of breath sounds and respiratory rate before and after procedure
Significant changes in vital signs
Color, amount and consistency of sputum

24. When documenting outcome of Richard�s treatment Mario should include the following in his recording EXCEPT:

Amount of fluid intake of client before and after the procedure
Significant changes in vital signs
Character of breath sounds and respiratory rate before and after procedure
Color, amount and consistency of sputum

25. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

Doctor
Teaching the client's relatives to perform the procedure
Respiratory rate, breath sounds and location of congestion
Amount of food and fluid taken during the last meal before treatment

26. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

Teaching the client�s relatives to perform the procedure
Doctor�s order regarding position restrictions and client�s tolerance for lying flat
Respiratory rate, breath sounds and location of congestion
Amount of food and fluid taken during the last meal before treatment

27. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?

Time of last food and fluid intake of the client
Respiratory rate of 16 to 20 per minute
Client has no signs of infection
Client can tolerate sitting and lying positions

28. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?

Time of last food and fluid intake of the client
Respiratory rate of 16 to 20 per minute
Client has no signs of infection
Client can tolerate sitting and lying positions

29. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

In both percussion and vibration the hands are on top of each other and hand action is in tune with client
Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air
Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle
Percussion uses only one hand while vibration uses both hands

30. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle
In both percussion and vibration the hands are on top of each other and hand action is in tune with client�s breath rhythm
Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air
Percussion uses only one hand while vibration uses both hands

31. Situation 4 - A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client.

16. When doing an initial assessment, the best way for you to identify the client's priority problem is to:

Talk to the relatives to gather data about history of illness
Interview the client for chief complaints and other symptoms
Do a physical examination while asking the client relevant questions
Do auscultation to check for chest congestion

32. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client.

16. When doing an initial assessment, the best way for you to identify the client�s priority problem is to:

Talk to the relatives to gather data about history of illness
Do auscultation to check for chest congestion
Interview the client for chief complaints and other symptoms
Do a physical examination while asking the client relevant questions

33. Upon establishing Mr. Regalado's nursing needs, the next nursing approach would be to:

Introduce the client to the ward staff to put the client and family at ease
Establish priority needs and implement appropriate interventions
Take his vital signs for a baseline assessment
Give client and relatives a brief tour of the physical set up the unit

34. Upon establishing Mr. Regalado�s nursing needs, the next nursing approach would be to:

Give client and relatives a brief tour of the physical set up the unit
Take his vital signs for a baseline assessment
Introduce the client to the ward staff to put the client and family at ease
Establish priority needs and implement appropriate interventions

35. Mr. Regalado says he has 'trouble going to sleep'. In order to plan your nursing intervention you will:

Take his blood pressure before sleeping and upon waking up
Ask him what he means by this statement
Observe his sleeping patterns in the next few days
Check his physical environment to decrease noise level

36. Mr. Regalado says he has �trouble going to sleep�. In order to plan your nursing intervention you will:

Observe his sleeping patterns in the next few days
Check his physical environment to decrease noise level
Ask him what he means by this statement
Take his blood pressure before sleeping and upon waking up

37. Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing approach?

Moisturize lower extremities to prevent skin irritation
Provide the client a list of food low in sodium
Elevate lower extremities for postural drainage
Measure fluid intake and output to decrease edema

38. Mr. Regalado�s lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing approach?

Measure fluid intake and output to decrease edema
Provide the client a list of food low in sodium
Elevate lower extremities for postural drainage
Moisturize lower extremities to prevent skin irritation

39. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT:

Giving instructions about his medication regimen
Proper recording of pertinent data
Making a final physical assessment before client leaves the hospital
Walking the client to the hospital exit to ensure his safety

40. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT:

Walking the client to the hospital exit to ensure his safety
Proper recording of pertinent data
Giving instructions about his medication regimen
Making a final physical assessment before client leaves the hospital

41. Situation 5 - Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told that she has breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension.

21. Considering her level of anxiety, the nurse can best assist Nancy by:

Giving her clear but brief information at the level of her understanding
Preparing her and her family in case surgery is not successful
Giving her activities to divert her attention
Giving detailed explanations about the treatments she will undergo

42. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension.

21. Considering her level of anxiety, the nurse can best assist Nancy by:

Giving her activities to divert her attention
Giving her clear but brief information at the level of her understanding
Giving detailed explanations about the treatments she will undergo
Preparing her and her family in case surgery is not successful

43. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:

bargaining
anger
acceptance
denial

44. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of:

denial
acceptance
anger
bargaining

45. The nurse visits Nancy and prods her to eat her food. Nancy replies 'what

'The doctor ordered full diet for you so that you will be strong for surgery'
'I understand how you feel but you have to try for your children
'Have you told your doctor how you feel? Are you changing your mind about your surgery?'
'You sound like you are giving up.'

46. The nurse visits Nancy and prods her to eat her food. Nancy replies �what�s the use? My time is running out.� The nurse�s best response would be:

�The doctor ordered full diet for you so that you will be strong for surgery�
�I understand how you feel but you have to try for your children�s sake�
�You sound like you are giving up.�
�Have you told your doctor how you feel? Are you changing your mind about your surgery?�

47. The nurse feels sad about Nancy

Reassure the nurse that the client has hope if she goes through all treatments prescribed for her
Assign the nurse to another client to avoid sympathy for the client
Advise the nurse to 'be strong and learn to control her feelings'
Ask the other nurses what they feel about the patient to find out if they share the same feelings

48. The nurse feels sad about Nancy�s illness and tells her head nurse during the end of shift endorsement that �it�s unfair for Nancy to have cancer when she is still so young and with two kids�. The best response of the head nurse would be:

Assign the nurse to another client to avoid sympathy for the client
Reassure the nurse that the client has hope if she goes through all treatments prescribed for her
Advise the nurse to �be strong and learn to control her feelings�
Ask the other nurses what they feel about the patient to find out if they share the same feelings

49. Realizing that she feels angry about Nancy's condition, the nurse learns that being self-aware is a conscious process that she should do in any situation like this because:

How the nurse thinks and feels affect her actions towards her client and her work
The nurse is a role model for the client and should be strong
This is a necessary part of the nurse
The nurse has to be therapeutic at all times and should not be affected

50. Realizing that she feels angry about Nancy�s condition, the nurse learns that being self-aware is a conscious process that she should do in any situation like this because:

The nurse has to be therapeutic at all times and should not be affected
How the nurse thinks and feels affect her actions towards her client and her work
The nurse is a role model for the client and should be strong
This is a necessary part of the nurse � client relationship process

51. Situation 6 - Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage.

26. Instruction on health promotion regarding urinary elimination is important. Which would you include?

After urination, wipe from anal area up towards the pubis
Tell client to empty the bladder at each voiding
If burning sensation is experienced while voiding, drink pineapple juice
Hold urine as long as she can before emptying the bladder to strengthen her sphincter muscles

52. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage.

26. Instruction on health promotion regarding urinary elimination is important. Which would you include?

After urination, wipe from anal area up towards the pubis
If burning sensation is experienced while voiding, drink pineapple juice
Tell client to empty the bladder at each voiding
Hold urine as long as she can before emptying the bladder to strengthen her sphincter muscles

53. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?

decreased ability to absorb fluids in the lower intestines
loss of tone of the smooth muscles of the colon
inhibition of the parasympathetic reflex
weakness of sphincter muscles of anus

54. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?

decreased ability to absorb fluids in the lower intestines
weakness of sphincter muscles of anus
inhibition of the parasympathetic reflex
loss of tone of the smooth muscles of the colon

55. The nurse understands that one of these factors contributes to constipation:

prolonged use of laxatives
excessive exercise
no regular time for defecation daily
high fiber diet

56. The nurse understands that one of these factors contributes to constipation:

high fiber diet
prolonged use of laxatives
excessive exercise
no regular time for defecation daily

57. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate instruction would be to:

instruct client to start wearing thin adult diapers
ask the client to bring change of underwear
teach client pelvic exercise to strengthen perineal muscles
tell client to drink less fluids to avoid accidents

58. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing and when she has a full bladder. Your most appropriate instruction would be to:

ask the client to bring change of underwear �just in case�
tell client to drink less fluids to avoid accidents
teach client pelvic exercise to strengthen perineal muscles
instruct client to start wearing thin adult diapers

59. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by:

Drying the skin with baby powder to prevent or mask the smell of ammonia
Using thick diapers to absorb urine well
Thorough washing, rising and drying of skin area that get wet with urine
Making sure that linen are smooth and dry at all times

60. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by:

Using thick diapers to absorb urine well
Thorough washing, rising and drying of skin area that get wet with urine
Making sure that linen are smooth and dry at all times
Drying the skin with baby powder to prevent or mask the smell of ammonia

61. Situation 7 - Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse's knowledge and ability to identify and immediately intervene to meet these needs is important to save lives.

Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:

Theresa with anemia
Sonnyboy with a fracture in the femur
Brigitte with diarrhea
Carol with tumor in the brain

62. The nurse�s knowledge and ability to identify and immediately intervene to meet these needs is important to save lives.

31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:

Theresa with anemia
Sonnyboy with a fracture in the femur
Carol with tumor in the brain
Brigitte with diarrhea

63. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition is called:

Cyanosis
Hypoxemia
Anemia
Hypoxia

64. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition is called:

Hypoxemia
Cyanosis
Anemia
Hypoxia

65. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:

the distance from the tip of the nose to the tip of the ear lobe
eight to ten inches
the distance from the tip of the nose to the middle of the neck
tip of the nose to the base of the neck

66. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:

the distance from the tip of the nose to the tip of the ear lobe
eight to ten inches
tip of the nose to the base of the neck
the distance from the tip of the nose to the middle of the neck

67. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:

Applying no suction while inserting the catheter
Rotating catheter as it is inserter with gentle suction
Using gloves to prevent introduction of pathogens to the respiratory system
Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed

68. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:

Using gloves to prevent introduction of pathogens to the respiratory system
Apply suction for at least 20-30 seconds each time to ensure that all secretions are removed
Applying no suction while inserting the catheter
Rotating catheter as it is inserter with gentle suction

69. Myrna has difficulty breathing when on her back and must sit upright in bed to breath effectively and comfortably. The nurse documents this condition as:

Orthopnea
Dyspnea
Tachypnea
Apnea

70. Myrna has difficulty breathing when on her back and must sit upright in bed to breath effectively and comfortably. The nurse documents this condition as:

Tachypnea
Dyspnea
Apnea
Orthopnea

71. Situation 8 - You are assigned to screen for hypertension. Your task is to take blood pressure readings and you are informed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood pressure readings.

36. When taking blood pressure reading the cuff should be:

deflated fully then immediately start second reading for same client
inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery
deflated quickly after inflating up to 180 mmHg
large enough to wrap around upper arm of the adult client 1 cm above brachial artery

72. Your task is to take blood pressure readings and you are informed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood pressure readings.

36. When taking blood pressure reading the cuff should be:

large enough to wrap around upper arm of the adult client 1 cm above brachial artery
deflated quickly after inflating up to 180 mmHg
inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery
deflated fully then immediately start second reading for same client

73. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death world wide and is a preventable disease. The primary cause of COPD is

bronchitis
cigarette smoking
asthma
tobacco hack

74. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death world wide and is a preventable disease. The primary cause of COPD is

bronchitis
tobacco hack
asthma
cigarette smoking

75. In your health education class for clients with diabetes you teach them the areas for control of Diabetes which include all EXCEPT

prevention nutrition
thorough knowledge of foot care
proper nutrition
regular physical activity

76. In your health education class for clients with diabetes you teach them the areas for control of Diabetes which include all EXCEPT

proper nutrition
regular physical activity
thorough knowledge of foot care
prevention nutrition

77. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the following is true?

Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology
Type I (IIDM) is characterized by fasting hyperglycemia
Type II (NIDDM) is characterized by abnormal immune response
both types diabetes mellitus clients are all prone to developing ketosis

78. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the following is true?

both types diabetes mellitus clients are all prone to developing ketosis
Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology
Type I (IIDM) is characterized by fasting hyperglycemia
Type II (NIDDM) is characterized by abnormal immune response

79. Lifestyle-related diseases in general share areas common risk factors. These are the following except:

genetics
nutrition
physical activity
smoking

80. Lifestyle-related diseases in general share areas common risk factors. These are the following except:

smoking
genetics
nutrition
physical activity

81. Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of the accident

41. Her priority nursing action would be to:

Report the incident immediately to the local police authorities
Assess the extent of injuries incurred by the victims of the accident
Assess damage to property
Assist in the police investigation since she is a witness

82. She decides to get involved and help the victims of the accident

41. Her priority nursing action would be to:

Assess damage to property
Assist in the police investigation since she is a witness
Report the incident immediately to the local police authorities
Assess the extent of injuries incurred by the victims of the accident

83. Priority attention should be given to which of these clients?

Andy whose left ankle swelled and has some abrasions
Linda who shows severe anxiety due to trauma of the accident
Ryan who has chest injury, is pale and with difficulty breathing
Noel who has lacerations on the arms with mild bleeding

84. Priority attention should be given to which of these clients?

Ryan who has chest injury, is pale and with difficulty breathing
Noel who has lacerations on the arms with mild bleeding
Andy whose left ankle swelled and has some abrasions
Linda who shows severe anxiety due to trauma of the accident

85. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms. While assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to:

Apply antiseptic to prevent infection
Bandage the wound and elevate the arm
Control and reduce bleeding of the wound
Clean the wound vigorously of contaminants

86. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the arms. While assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to:

Clean the wound vigorously of contaminants
Bandage the wound and elevate the arm
Control and reduce bleeding of the wound
Apply antiseptic to prevent infection

87. The nurse applies dressing on the bleeding site. This intervention is done to:

Allow the pus to surface faster
Reduce the need to change dressing frequently
Promote hemostasis
Protect the wound from microorganisms in the air

88. The nurse applies dressing on the bleeding site. This intervention is done to:

Promote hemostasis
Allow the pus to surface faster
Protect the wound from microorganisms in the air
Reduce the need to change dressing frequently

89. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities when the client is to be discharged include the following EXCEPT:

Instructing the client to see you after discharge for further assistance
Accurate recording of treatment done and instructions given to client
Encouraging the client to go to the outpatient clinic for follow up care
Providing instructions regarding wound care

90. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities when the client is to be discharged include the following EXCEPT:

Instructing the client to see you after discharge for further assistance
Accurate recording of treatment done and instructions given to client
Providing instructions regarding wound care
Encouraging the client to go to the outpatient clinic for follow up care

91. Situation 10 - While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor's appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an assessment.

46. The purpose of your initial nursing interview is to:

Make nursing diagnoses for identified health problems
Assist the client find solutions to he her health concerns
Understand her lifestyle, health needs and possible problems to develop a plan of care
Record pertinent information in the client

92. As the clinic nurse, you are to assist the client fill up forms, gather data and make an assessment.

46. The purpose of your initial nursing interview is to:

Assist the client find solutions to he her health concerns
Make nursing diagnoses for identified health problems
Record pertinent information in the client�s chart for health team to read
Understand her lifestyle, health needs and possible problems to develop a plan of care

93. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that this pain occurs about an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows:

Claims to have abdominal pains after intake of coffee unrelieved by analgesics
After drinking coffee, the client experienced severe abdominal pain
Client complained of intermittent abdominal pain an hour after drinking coffee
Client reported abdominal pain an hour after drinking black coffee for three weeks now.

94. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that this pain occurs about an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows:

Client reported abdominal pain an hour after drinking black coffee for three weeks now.
Client complained of intermittent abdominal pain an hour after drinking coffee
Claims to have abdominal pains after intake of coffee unrelieved by analgesics
After drinking coffee, the client experienced severe abdominal pain

95. Geline tells you that she drinks black coffee frequently within the day to 'have energy and be wide awake' and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks. In planning a healthy balanced diet with Geline, you will:

Plan a high protein diet, low carbohydrate diet for her considering her favorite food.
Discuss with her the importance of eating a variety of food from major food groups with plenty of fluids.
Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily high energy level.
Start her off with a cleansing diet to free her body of toxins then change to a vegetarian diet and drink plenty of fluids

96. Geline tells you that she drinks black coffee frequently within the day to �have energy and be wide awake� and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks. In planning a healthy balanced diet with Geline, you will:

Start her off with a cleansing diet to free her body of toxins then change to a vegetarian diet and drink plenty of fluids
Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain daily high energy level.
Discuss with her the importance of eating a variety of food from major food groups with plenty of fluids.
Plan a high protein diet, low carbohydrate diet for her considering her favorite food.

97. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but does not want to become fat that is why she limits her food intake. You warn or caution her about which of the following?

Malnutrition and its possible effects on growth and development problems in the unborn fetus
Caffeine causes a stimulant effect on both mother and the baby
Caffeine products affect the central nervous system and may cause the mother to have a 'nervous breakdown'
Studies show conclusively that caffeine causes mental retardation

98. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but does not want to become fat that is why she limits her food intake. You warn or caution her about which of the following?

Caffeine causes a stimulant effect on both mother and the baby
Caffeine products affect the central nervous system and may cause the mother to have a �nervous breakdown�
Malnutrition and its possible effects on growth and development problems in the unborn fetus
Studies show conclusively that caffeine causes mental retardation

99. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of noncommunicable diseases that are influenced by her lifestyle. These include the following EXCEPT:

Cardiovascular diseases
Diabetes Mellitus
Cancer
Osteoporosis

100. Your health education plan for Geline stresses proper diet for a pregnant woman and the prevention of noncommunicable diseases that are influenced by her lifestyle. These include the following EXCEPT:

Cardiovascular diseases
Cancer
Osteoporosis
Diabetes Mellitus

Nursing practice i � foundation of professional nu

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