A.
Flush
B.
Cyanosis
C.
Jaundice
D.
Pallor
2. The term gavage indicates:
A.
Administration
of a liquid feeding into the stomach
B.
Visual
examination of the stomach
C.
Irrigation
of the stomach with a solution
D.
A
surgical opening through the abdomen to the stomach
3. A patient states that he has difficulty
sleeping in the hospital because of noise. Which of the following would be an
appropriate nursing action?
A.
Administer
a sedative at bedtime, as ordered by the physician
B.
Ambulate
the patient for 5 minutes before he retires
C.
Give
the patient a glass of warm milk before bedtime
D.
Close
the patient’s door from 9pm to 7am
4. Which of the following nursing theorists
dveloped a conceptual model based on the belief that all persons strive to achieve
self-care?
A.
Martha
Rogers
B.
Dorothea
Orem
C.
Florence
Nightingale
D.
Cister
Callista Roy
5. Which of the following nursing theorists is
credited with developing a conceptual model specific to nursing, with man as
the central focus?
A.
Martha
Rogers
B.
Dorothea
Orem
C.
Florence
Nightingale
D.
Sister
Callista Roy
6. Which of the following questions is most
appropriate to ask when interviewing a potential candidate fo an RN position?
A.
What
was your last nursing experience?
B.
Are
you willing to do overtime on weekends?
C.
How
many children do you have?
D.
Do
you plan to get pregnant?
7. If a patient is injured because a nurse acted
in a wrongful manner, which party could be held liable along with the nurse?
A.
The
private attending physician
B.
The
nursing supervisor
C.
The
hospital
D.
All
of the above
8. Which of the following may be considered a
patient’s right?
A.
The
right to euthanasia
B.
The
right to refuse treatment
C.
The
right to ignore hospital regulations
D.
The
right to refuse to pay for what the patient considers to be inferior service.
9. If a patient sues a nurse for malpractice,
the patient must be able to prove:
A.
Error,
proximal cause, and lack of concern
B.
Error,
injury and proximal cause
C.
Injury,
error and assault
D.
Proximal
cause, negligence and nurse error
10. Which communication skills is most effective
in dealing with covert communication?
A.
Validation
B.
Listening
C.
Evaluation
D.
Clarification
11. Which of the following qualities are
relevant in documenting patient care?
A.
Accuracy
and conciseness
B.
Thoroughness
and currentness
C.
Organization
D.
All
of the above
12. The usual sequence for assessing the bowel
is:
A.
Right
lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant
B.
Right
lower lobe, right upper lobe, left upper lobe, left lower lobe
C.
Right
hypochondriac, left hypochondriac and umbilical regions
D.
Rectum,
pancreas, stomach and liver
13. The nurse should take a rectal temperature
of a patient who has:
A.
His
arm in a cast
B.
Nasal
packing
C.
External
hemorrhoids
D.
Gastrostomy
feeding tubes
14. Blood pressure measurement is an important
part of the patient’s data base. It is considered to be:
A.
The
basis of the nursing diagnosis
B.
Objective
data
C.
An
indicator of the patient’s well being
D.
Subjective
data
15. Postural drainage to relieve respiratory
congestion should take place:
A.
Before
meals
B.
After
meals
C.
At
the nurse’s convenience
D.
At
the patient’s convenience
16. The correct site at which to verify a radial
pulse measurement is the:
A.
Brachial
artery
B.
Apex
of the heart
C.
Temporal
artery
D.
Inguinal
site
17. S1 is heard best at the:
A.
5th
left intercoastal space along the midclavicular line
B.
3rd
intercoastal space to the left of the midclavicular line
C.
Second
right intercoastal space at the sternal border
D.
Second
left intercoastal space at the sternal border
18. The nurse’s main priority when caring foar a
patient with hemiplegia?
A.
Educating
the patient
B.
Providing
a safe environment
C.
Promoting
a positive self-image
D.
Helping
the patient accept the illness
19. Constipation is a common problem for
immobilized patients because of:
A.
Decreased
peristalsis and positional discomfort
B.
An
increased defacation reflex
C.
Decreased
tightening of the anal sphincter
D.
Increased
colon motility
20. Antiembolism stockings are used primarily
to:
A.
Promote
venous circulation
B.
Provide
external warmth
C.
Prevent
dependent edema
D.
Hold
foot dressings
21. To promote correct anatomic alignment in a
supine patient, the nurse should:
A.
Place
the patient’s feet in dorsiflexion
B.
Place
a pillow under the patient’s knees
C.
Hyperextend
the patient’s neck
D.
Adduct
the patient’s shoulder
22. An appropriate interdependent intervention
to prevent thrombophebitis would be:
A.
Elevate
the knee gatch of the bed
B.
Massage
the legs vigorously
C.
Apply
antiembolism stockings to both legs.
D.
Encourage
the patient to sit with his knees crossed
23. The average daily amount of urine excreted
by an adult is:
A.
500
to 600 ml
B.
800
to 1,400 ml
C.
1,000
to 1,200 ml
D.
1,500
to 2,000 ml
24. According to Maslow’s hierarchy of needs,
which of the following is a basic physiologic need after oxygen?
A.
Activity
B.
Safety
C.
Love
D.
Self
esteem
25. Mr. Jose is admitted to the hospitalwith a
diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for
him. The most comfortable method of delivering oxygen to Mr. Jose is by:
A.
Croupette
B.
Nasal
Cannula
C.
Nasal
catheter
D.
Partial
rebreathing mask
Answers and Rationales
1.
Answer : (A) Flush. Flush is a sudden redness of the skin.
Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal
amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration
of the skin, mucous membranes and sclerae caused by excessive amounts of
bilirubin in the blood. Pallor is an unnatural paleness or absence of color in
the skin indicating insufficient oxygen and excessive carbon dioxide in the
blood.
2.
Answer :(A) Administration of a liquid feeding into the
stomach. Gavage
is the administration of a liquid feeding into the stomach
3.
Answer :(C) Give the patient a glass of warm milk before
bedtime. Warm
milk will relax the patient because it contains tryptophan, a natural sedative.
4.
Answer :(B) Dorothea Orem. Dorothea Orem’s
conceptual model is based on the premise that all persons need to achieve
self-care. She also views the goal of nursing as helping the patient to develop
self-care practices to maintain maximum wellness.
5.
Answer
:(A) Martha Rogers. Martha Roger’s life process model views man as an
evolving creature interacting with the environment in an open, adaptive manner.
According to this model, the purpose of nursing is to help man achieve maximum
health in his environment.
6.
Answer :(A) What was your last nursing experience?. An interviewer’s
question should center on the applicant’s qualifications for the position.
Questions about the applicant’s personal life are inappropriate and may be
illegal.
7.
Answer :(C) The hospital. Under the master servant
rule (also known as the doctrine or respondeat superior), when a person is
injured by an employee as a result of negligence in the course of the
employee’s work, the employer is responsible to the injured person.
8.
Answer :(B) The right to refuse treatment. Under the bill of rights
law, the patient has the right to refuse treatment/life – giving measures, to
the extent permitted by law, and to be informed of the medical consequences of
his action.
9.
Answer :(B) Error, injury and proximal cause. Three criteria must be
met to establish malpractice: a nursing error, a patient injury, and a
connection between the two.
10.
Answer :(A) Validation. Covert communication
reflects inner feelings that a person may be uncomfortable talking about. Such
communication may be revealed through body language, silence, withdrawn
behavior, or crying. Validation is an attempt to confirm the observer’s
perceptions through feedback, interpretation and clarification.
11.
Answer :(D) All of the above. Documentation should
leave no room for misinterpretation. Thus, the nurse must ensure that all
information pertinent to patient care is reworded accurately, concisely and
thoroughly. The information must be up-to-date and well organized.
12.
Answer :(A) Right lower quadrant, right upper quadrant, left
upper quadrant. left lower quadrant. This sequence follows the anatomy of the
bowel. The lobes are parts of the lung. the right and left hypochondriac and
the umbilical area are three of the nine regions of the abdomen.
13.
Answer :(B) Nasal packing. A rectal temperature is
usually recommended whenever an oral temperature is contraindicated (e.g. the
patient who have undergone oral or nasal surgery, infants and those who have
history of seizures, etc). However, a rectal temperature is contraindicated in
patients having rectal disease, rectal surgery or diarrhea)
14.
Answer :(B) Objective data. Objective data are those
such as BP, which can be measured or perceived by someone other than the
patient. Subjective data are those such as pain, which only the patient can
perceive.
15.
Answer :(A) Before meals. Postural drainage is
best performed before, rather after meals to avoid tiring the patient or
inducing vomiting. The patient’s safety supersedes the convenience in
scheduling this procedure.
16.
Answer :(B) Apex of the heart. The best site for
verifying a pulse rate is the apex of the heart, where the heartbeat is measured
directly.
17.
Answer :(A) 5th left intercoastal space along the
midclavicular line. The S1 heart sound is best heard at the apex of the heart,
at the fifth intercoastal space along the midclavicular line. (An infant’s apex
is located at the third or fourth intercoastal space just to the left of the
midclavicular line)
18.
Answer :(B) Providing a safe environment. A patient with
hemiplegia (paralysis of one side of the body) has a high risk of injury
because of his altered motor and sensory function, so safety is the nurse’s
main priority.
19.
Answer :(A) Decreased peristalsis and positional
discomfort. Increased
adrenalin production in the immobile patient results in decrease peristalsis
and colon motility and more tightly constricted sphincters.
20.
Answer :(A) Promote venous circulation. Antiembolism stockings
are elastic stockings designed to maintain compression of small veins and
capillaries in the legs.
21.
Answer :(A) Place the patient’s feet in dorsiflexion. Anatomic alignment
prevents strain on body parts, maintains balance, and promotes physiologic
functioning. To promote this position, the nurse should place the feet in
dorsiflexion (at right angles to the legs)
22.
Answer :(C) Apply antiembolism stockings to both
legs.. Antiembolism
stockings increase venous return to the heart, which helps prevent
thromboplebitis.
23.
Answer :(D) 1,500 to 2,000 ml. An adult’s average urine
output ranges between 1,500 and 2,000 ml/day.
24.
Answer :(A) Activity. According to Maslow,
activity is one of the man’s most basic physiologic needs, along with oxygen,
shelter, food, water, erst, sleep and temperature maintenance.
25.
Answer :(B) Nasal Cannula. The nasal cannula is the
most comfortable method of delivering oxygen because it allows the patient to
talk, eat and drink.