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

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