Post on 01-Nov-2014
Embed Size (px)
1. Which option serves as a framework for nursing education and clinical practice? A. Scientific Breakthroughs B. Technical Advances C. Theoretical models D. Medical Practices Answer : C. Rationale: Theoretical models of nursing provide the foundation of all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment and nursing.Scientific Breakthroughs, technological models, medical practices may affect nursing but arent frameworks for nursing education and practices.
Fundamentals of Nursing by Kozier and Erbs: pg. 11 Eight Edition2. The nurse must assess the skin turgor of an elderly client. When evaluating skin turgor the skin should remember that: A. Over hydration of the skin to tent B. Dehydration causes the skin to appear edematous and spongy C. Inelastic skin turgor is a normal part of aging D. Normal skin turgor is moist and boggy. Answer: C Rationale: Inelastic skin turgor is normal part of aging.
Fundamentals of Nursing by Kozier and Erbs: pg. 411 Eight Edition3. When positioned properly, the tip of central nervous catheter should lie in the: A. Superior Vena Cava B. Basilic Vein C. Jugular Vein D. Sublaclavian Vein Answer: A Rationale: When the Central Nervous Vena Cava is positioned correctly, its tip lies in the superior vena cava, Inferior Vena Cava, or right atrium that is in the central venous circulation. Blood flows unimpeded around the tip allowing the rapid infusion of large amounts of fluid. The basilica jugular, and subclavian veins are common insertion sites central nervous catheters.
Fundamentals of Nursing by Kozie, Erb, Berman, Snyder: pg. 1382 Seventh Edition4. Which of the following sentences is correctly describes the anatomic position? A. The body is supine B. Arms are elevated at the shoulder level
C. Palms are turned forward D. The body is facing backward Answer: A Rationale: In the anatomic position, the body is erect, facing forward with arms the sides and palms turned forward.
Fundamentals of Nursing by Kozier and Erb: 956 Eight Edition5. At 8:00 am, the nurse should assess a client whos scheduled for surgery at 10:00am. During the assessment the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next? A. Check to see that the chest X-ray was done yesterday as ordered. B. Check the serum electrolyte levels and complete blood count (CBC) C. Notify the physician immediately of this finding. D. Sign the preoperative checklist for this client. Answer: C Rationale: The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may sign changes in the clients respiratory status.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 403 Seventh Edition6. The physician order Ampicillin (Omnipen) 500mg by mouth q6. This medication order is an example of: A. Standard written order. B. A single Order C. PRN order D. a stat order Answer: A Rationale: A standard written order is an order that applies until the prescriber writes another order to alter or discontinue the first one. A single order allows for one time dose only, and PRN order allows drug administration when the clients need it. A stat order includes such words now or immediately.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 794 Seventh Editions7. To measures the client temperature at 102 F o. What is the equivalent centigrade temperature/ A. 39oC B. 74oC C. 38.9oC D. 40.1oC Answer: 3 Rationale: To convert Fahrenheit degrees to Centigrade use this formula:
C = (oF-32) 1.8 C = (102-32) 1.8
o o o
C = 70 1.8 C = 38.9
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 494 Seventh Editions8. A client reports abdominal pain. Which action would aid the nurses investigation of this complaint? A. Using deep palpation B. Assessing the painful area last C. Assessing the painful area first D. Checking for warmth in the painful area Answer: B Rationale: Assessing the painful area last allows the nurse to obtain the, maximal amount of information with minimal client discomfort. To prepare the client, the nurse should always let the client know when painful area will be assessed. Pressure resulting deep palpation may cause rupture of an underlying mass. Checking for warmth in the painful area offers no real information about the clients pain.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 597 Seventh Editions9. The nurse gives a client the wrong medication, after assessing the client; the nurse completes an incident report. Which statement describes what will occur next? A. The incident reported to the state board of disciplinary action. B. The incident will be documented in the nurses personnel file. C. The medication error will result in the nurse being suspended and possibly, terminated from employment at the facility. D. The incident report is a method of promoting quality care and risk management. Answer: D Rationale: Unusual occurrence and deviations from care are documented on incident reports. Incident reports are internal to the facility and are used to evaluate care, determine potential risk, or discover system problems that could have attributed to the error.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 63 Seventh Editions10. When preparing a client for bronchoscopy, the nurse should instruct the client not to? A. Walk B. Cough C. Talk D. Eat Answer: D
Rationale: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg.1446 Seventh Edition11. Which are the stages of grief that a client or family go through? A. Acceptance, Depression, Anger, Bargaining and Denial B. Depression, Anger, Bargaining, Acceptance and Denial C. Bargaining, Depression, Denial, Anger and Acceptance D. Denial, Anger, Bargaining, Depression, and Acceptance Answer: D Rationale: Denial is the avoidance of deaths inevitability and is the first step of grieving process. Anger, most intense grief reaction, arises when people realize that death and loss will actually occur or has occurred for a family member. Bargaining, happens when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss thats expressed or profound sadness or deep suffering. Acceptance is the final stage, and its the ability to overcome the grief and accept what has happened.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 1055 Seventh Edition12. The nurse is assessing a clients abdomen, which finding should the nurse report as an abnormal/ A. Dullness over the liver B. Bowel sound occurring every 10 seconds C. Shifting dullness over the abdomen D. Vascular sound heard over the artery Answer: C Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options the other options are normal abdominal findings.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 594 Seventh Edition13. When caring for a client, the nurse must determine whether the client has achieved the goals established in the care plan. The nurse determines goal achievement during which step of the nursing process? A. Evaluation B. Planning C. Assessment D. Implementation Answer: A Rationale: During evaluation, the nurse assesses the clients goal achievement by comparing the actual outcome identified during the planning step of the nursing process.
Fundamentals of Nursing by Kozier and Erb: pg. 235 Eight Edition
14. When performing an abdominal assessment, the nurse should follow which examination sequence? A. Inspection, auscultation, percussion and palpation B. Ausculatation, Percussion, Palpation, and Inspection C. Percussion, Auscultation, Inspection, and Auscultation D. Auscultation, Inspection, Percussion, and Palpation Answer: A Rationale: The correct sequence for abdominal assessment in inspection is Inspection, auscultation, percussion and palpation because this sequence prevents altering bowel sound before auscultation.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 597 Seventh Edition15. When prioritizing a clients care plan based on Maslows Hierarchy of needs, the nurses first prioritize would be: A. allowing the family to see a newly admitted client B. Ambulating the client in the hallway C. Administering pain medication D. Placing wrist restraints on the client Answer: C Rationale: In Maslows Hierarcy of needs, pain relief is on the first layer.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg. 197 Seventh Edition16. A client is admitted with acute chest pain. When obtaining the health history, which question would be most helpful for the nurse to ask/ A. Do you need anything now? B. Why do you think you had a heart attack? C. What were you doing when the pain started? D. Has anyone in your family been sick lately? Answer: C Rationale: Subjective Data about the chest pain help determine the specific health problem. Asking about bout the setting in which the pain developed can provide helpful information about its cause.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg.1289 Seventh Edition17. When teaching a client with how to take a sublingual tablet, the nurse should instruct the client to place the tablet on the: A. Top of the mouth B. Roof of the mouth
C. Floor of the mouth D. Inside f the cheek Answer: C. Rationale: The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth.
Fundamentals of Nursing by Kozier, Erb, Berman, Snyder: pg.807 Seventh Edition18. The nurs