Fundamentals of Nursing Practice
Exam
A.
Host
B.
Reservoir
C.
Mode of
transmission
D.
Portal of entry
2.
Which of the following will probably result in a break in sterile technique for
respiratory isolation?
A.
Opening the
patient’s window to the outside environment
B.
Turning on the
patient’s room ventilator
C.
Opening the door
of the patient’s room leading into the hospital corridor
D.
Failing to wear
gloves when administering a bed bath
3.
Which of the following patients is at greater risk for contracting an
infection?
A.
A patient with
leukopenia
B.
A patient
receiving broad-spectrum antibiotics
C.
A postoperative
patient who has undergone orthopedic surgery
D.
A newly diagnosed
diabetic patient
4.
Effective hand washing requires the use of:
A.
Soap or detergent
to promote emulsification
B.
Hot water to
destroy bacteria
C.
A disinfectant to
increase surface tension
D.
All of the above
5.
After routine patient contact, hand washing should last at least:
A.
30 seconds
B.
1 minute
C.
2 minute
D.
3 minutes
6.
Which of the following procedures always requires surgical asepsis?
A.
Vaginal
instillation of conjugated estrogen
B.
Urinary
catheterization
C.
Nasogastric tube
insertion
D.
Colostomy
irrigation
7.
Sterile technique is used whenever:
A.
Strict isolation
is required
B.
Terminal
disinfection is performed
C.
Invasive
procedures are performed
D.
Protective
isolation is necessary
8.
Which of the following constitutes a break in sterile technique while preparing
a sterile field for a dressing change?
A.
Using sterile
forceps, rather than sterile gloves, to handle a sterile item
B.
Touching the
outside wrapper of sterilized material without sterile gloves
C.
Placing a sterile
object on the edge of the sterile field
D.
Pouring out a
small amount of solution (15 to 30 ml) before pouring the solution into a
sterile container
9.
A natural body defense that plays an active role in preventing infection is:
A.
Yawning
B.
Body hair
C.
Hiccupping
D.
Rapid eye
movements
10.
All of the following statement are true about donning sterile gloves except:
A.
The first glove
should be picked up by grasping the inside of the cuff.
B.
The second glove
should be picked up by inserting the gloved fingers under the cuff outside the
glove.
C.
The gloves should
be adjusted by sliding the gloved fingers under the sterile cuff and pulling
the glove over the wrist
D.
The inside of the
glove is considered sterile
11.
When removing a contaminated gown, the nurse should be careful that the first
thing she touches is the:
A.
Waist tie and
neck tie at the back of the gown
B.
Waist tie in front
of the gown
C.
Cuffs of the gown
D.
Inside of the
gown
12.
Which of the following nursing interventions is considered the most effective
form or universal precautions?
A.
Cap all used
needles before removing them from their syringes
B.
Discard all used
uncapped needles and syringes in an impenetrable protective container
C.
Wear gloves when
administering IM injections
D.
Follow enteric
precautions
13.
All of the following measures are recommended to prevent pressure ulcers
except:
A.
Massaging the
reddened are with lotion
B.
Using a water or
air mattress
C.
Adhering to a
schedule for positioning and turning
D.
Providing
meticulous skin care
14.
Which of the following blood tests should be performed before a blood
transfusion?
A.
Prothrombin and
coagulation time
B.
Blood typing and
cross-matching
C.
Bleeding and
clotting time
D.
Complete blood
count (CBC) and electrolyte levels.
15.
The primary purpose of a platelet count is to evaluate the:
A.
Potential for
clot formation
B.
Potential for
bleeding
C.
Presence of an
antigen-antibody response
D.
Presence of
cardiac enzymes
16.
Which of the following white blood cell (WBC) counts clearly indicates
leukocytosis?
A.
4,500/mm³
B.
7,000/mm³
C.
10,000/mm³
D.
25,000/mm³
17.
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a
patient begins to exhibit fatigue, muscle cramping and muscle weakness. These
symptoms probably indicate that the patient is experiencing:
A.
Hypokalemia
B.
Hyperkalemia
C.
Anorexia
D.
Dysphagia
18.
Which of the following statements about chest X-ray is false?
A.
No contradictions
exist for this test
B.
Before the
procedure, the patient should remove all jewelry, metallic objects, and buttons
above the waist
C.
A signed consent
is not required
D.
Eating, drinking,
and medications are allowed before this test
19.
The most appropriate time for the nurse to obtain a sputum specimen for culture
is:
A.
Early in the
morning
B.
After the patient
eats a light breakfast
C.
After aerosol
therapy
D.
After chest
physiotherapy
20.
A patient with no known allergies is to receive penicillin every 6 hours. When
administering the medication, the nurse observes a fine rash on the patient’s
skin. The most appropriate nursing action would be to:
A.
Withhold the
moderation and notify the physician
B.
Administer the
medication and notify the physician
C.
Administer the
medication with an antihistamine
D.
Apply corn starch
soaks to the rash
21.
All of the following nursing interventions are correct when using the Z-track
method of drug injection except:
A.
Prepare the
injection site with alcohol
B.
Use a needle that’s
a least 1” long
C.
Aspirate for
blood before injection
D.
Rub the site
vigorously after the injection to promote absorption
22.
The correct method for determining the vastus lateralis site for I.M. injection
is to:
A.
Locate the upper
aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the
iliac crest
B.
Palpate the lower
edge of the acromion process and the midpoint lateral aspect of the arm
C.
Palpate a 1”
circular area anterior to the umbilicus
D.
Divide the area
between the greater femoral trochanter and the lateral femoral condyle into
thirds, and select the middle third on the anterior of the thigh
23.
The mid-deltoid injection site is seldom used for I.M. injections because it:
A.
Can accommodate
only 1 ml or less of medication
B.
Bruises too
easily
C.
Can be used only
when the patient is lying down
D.
Does not readily
parenteral medication
24.
The appropriate needle size for insulin injection is:
A.
18G, 1 ½” long
B.
22G, 1” long
C.
22G, 1 ½” long
D.
25G, 5/8” long
25.
The appropriate needle gauge for intradermal injection is:
A.
20G
B.
22G
C.
25G
D.
26G
26.
Parenteral penicillin can be administered as an:
A.
IM injection or
an IV solution
B.
IV or an
intradermal injection
C.
Intradermal or
subcutaneous injection
D.
IM or a
subcutaneous injection
27.
The physician orders gr 10 of aspirin for a patient. The equivalent dose in
milligrams is:
A.
0.6 mg
B.
10 mg
C.
60 mg
D.
600 mg
28.
The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What
would the flow rate be if the drop factor is 15 gtt = 1 ml?
A.
5 gtt/minute
B.
13 gtt/minute
C.
25 gtt/minute
D.
50 gtt/minute
29.
Which of the following is a sign or symptom of a hemolytic reaction to blood
transfusion?
A.
Hemoglobinuria
B.
Chest pain
C.
Urticaria
D.
Distended neck
veins
30.
Which of the following conditions may require fluid restriction?
A.
Fever
B.
Chronic
Obstructive Pulmonary Disease
C.
Renal Failure
D.
Dehydration
31.
All of the following are common signs and symptoms of phlebitis except:
A.
Pain or
discomfort at the IV insertion site
B.
Edema and warmth
at the IV insertion site
C.
A red streak
exiting the IV insertion site
D.
Frank bleeding at
the insertion site
32.
The best way of determining whether a patient has learned to instill ear
medication properly is for the nurse to:
A.
Ask the patient
if he/she has used ear drops before
B.
Have the patient
repeat the nurse’s instructions using her own words
C.
Demonstrate the
procedure to the patient and encourage to ask questions
D.
Ask the patient
to demonstrate the procedure
33.
Which of the following types of medications can be administered via gastrostomy
tube?
A.
Any oral
medications
B.
Capsules whole
contents are dissolve in water
C.
Enteric-coated
tablets that are thoroughly dissolved in water
D.
Most tablets
designed for oral use, except for extended-duration compounds
34.
A patient who develops hives after receiving an antibiotic is exhibiting drug:
A.
Tolerance
B.
Idiosyncrasy
C.
Synergism
D.
Allergy
35.
A patient has returned to his room after femoral arteriography. All of the
following are appropriate nursing interventions except:
A.
Assess femoral,
popliteal, and pedal pulses every 15 minutes for 2 hours
B.
Check the
pressure dressing for sanguineous drainage
C.
Assess a vital
signs every 15 minutes for 2 hours
D.
Order a
hemoglobin and hematocrit count 1 hour after the arteriography
36.
The nurse explains to a patient that a cough:
A.
Is a protective
response to clear the respiratory tract of irritants
B.
Is primarily a
voluntary action
C.
Is induced by the
administration of an antitussive drug
D.
Can be inhibited
by “splinting” the abdomen
37.
An infected patient has chills and begins shivering. The best nursing
intervention is to:
A.
Apply iced
alcohol sponges
B.
Provide increased
cool liquids
C.
Provide
additional bedclothes
D.
Provide increased
ventilation
38.
A clinical nurse specialist is a nurse who has:
A.
Been certified by
the National League for Nursing
B.
Received
credentials from the Philippine Nurses’ Association
C.
Graduated from an
associate degree program and is a registered professional nurse
D.
Completed a
master’s degree in the prescribed clinical area and is a registered
professional nurse.
39.
The purpose of increasing urine acidity through dietary means is to:
A.
Decrease burning
sensations
B.
Change the
urine’s color
C.
Change the
urine’s concentration
D.
Inhibit the
growth of microorganisms
40.
Clay colored stools indicate:
A.
Upper GI bleeding
B.
Impending
constipation
C.
An effect of
medication
D.
Bile obstruction
41.
In which step of the nursing process would the nurse ask a patient if the
medication she administered relieved his pain?
A.
Assessment
B.
Analysis
C.
Planning
D.
Evaluation
42.
All of the following are good sources of vitamin A except:
A.
White potatoes
B.
Carrots
C.
Apricots
D.
Egg yolks
43.
Which of the following is a primary nursing intervention necessary for all
patients with a Foley Catheter in place?
A.
Maintain the
drainage tubing and collection bag level with the patient’s bladder
B.
Irrigate the
patient with 1% Neosporin solution three times a daily
C.
Clamp the
catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D.
Maintain the
drainage tubing and collection bag below bladder level to facilitate drainage
by gravity
44.
The ELISA test is used to:
A.
Screen blood
donors for antibodies to human immunodeficiency virus (HIV)
B.
Test blood to be
used for transfusion for HIV antibodies
C.
Aid in diagnosing
a patient with AIDS
D.
All of the above
45.
The two blood vessels most commonly used for TPN infusion are the:
A.
Subclavian and
jugular veins
B.
Brachial and
subclavian veins
C.
Femoral and
subclavian veins
D.
Brachial and
femoral veins
46.
Effective skin disinfection before a surgical procedure includes which of the
following methods?
A.
Shaving the site
on the day before surgery
B.
Applying a
topical antiseptic to the skin on the evening before surgery
C.
Having the
patient take a tub bath on the morning of surgery
D.
Having the
patient shower with an antiseptic soap on the evening v=before and the morning
of surgery
47.
When transferring a patient from a bed to a chair, the nurse should use which
muscles to avoid back injury?
A.
Abdominal muscles
B.
Back muscles
C.
Leg muscles
D.
Upper arm muscles
48.
Thrombophlebitis typically develops in patients with which of the following
conditions?
A.
Increases partial
thromboplastin time
B.
Acute pulsus
paradoxus
C.
An impaired or
traumatized blood vessel wall
D.
Chronic
Obstructive Pulmonary Disease (COPD)
49.
In a recumbent, immobilized patient, lung ventilation can become altered,
leading to such respiratory complications as:
A.
Respiratory
acidosis, ateclectasis, and hypostatic pneumonia
B.
Appneustic
breathing, atypical pneumonia and respiratory alkalosis
C.
Cheyne-Strokes
respirations and spontaneous pneumothorax
D.
Kussmail’s
respirations and hypoventilation
50.
Immobility impairs bladder elimination, resulting in such disorders as
A.
Increased urine
acidity and relaxation of the perineal muscles, causing incontinence
B.
Urine retention,
bladder distention, and infection
C.
Diuresis,
natriuresis, and decreased urine specific gravity
D.
Decreased calcium
and phosphate levels in the urine
Answers and Rationales
1.
D. In the circular chain of infection, pathogens must
be able to leave their reservoir and be transmitted to a susceptible host
through a portal of entry, such as broken skin.
2.
C. Respiratory isolation, like strict isolation,
requires that the door to the door patient’s room remain closed. However, the
patient’s room should be well ventilated, so opening the window or turning on
the ventricular is desirable. The nurse does not need to wear gloves for
respiratoryisolation, but good hand washing is important for all types of
isolation.
3.
A. Leukopenia is a decreased number of leukocytes
(white blood cells), which are important in resisting infection. None of the
other situations would put the patient at risk for contracting an infection;
taking broad-spectrum antibiotics might actually reduce the infection risk.
4.
A. Soaps and detergents are used to help remove
bacteria because of their ability to lower the surface tension of water and act
as emulsifying agents. Hot water may lead to skin irritation or burns.
5.
A. Depending on the degree of exposure to pathogens,
hand washing may last from 10 seconds to 4 minutes. After routine patient
contact, hand washing for 30 seconds effectively minimizes the risk of pathogen
transmission.
6.
B. The urinary system is normally free of
microorganisms except at the urinary meatus. Any procedure that involves
entering this system must use surgically aseptic measures to maintain a
bacteria-free state.
7.
C. All invasive procedures, including surgery, catheter
insertion, and administration of parenteral therapy, require sterile technique
to maintain a sterile environment. All equipment must be sterile, and the nurse
and the physician must wear sterile gloves and maintain surgical asepsis. In
the operating room, the nurse and physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for all invasive procedures.
Strictisolation requires the use of clean gloves, masks, gowns and equipment to
prevent the transmission of highly communicable diseases by contact or by airborne
routes. Terminal disinfection is the disinfection of all contaminated supplies
and equipment after a patient has been discharged to prepare them for reuse by
another patient. The purpose of protective (reverse)isolation is to prevent a
person with seriously impaired resistance from coming into contact who
potentially pathogenic organisms.
8.
C. The edges of a sterile field are considered
contaminated. When sterile items are allowed to come in contact with the edges
of the field, the sterile items also become contaminated.
9.
B. Hair on or within body areas, such as the nose,
traps and holds particles that contain microorganisms. Yawning and hiccupping
do not prevent microorganisms from entering or leaving the body. Rapid eye
movement marks the stage of sleep during which dreaming occurs.
10. D. The
inside of the glove is always considered to be clean, but not sterile.
11. A. The back
of the gown is considered clean, the front is contaminated. So, after removing
gloves and washing hands, the nurse should untie the back of the gown; slowly
move backward away from the gown, holding the inside of the gown and keeping
the edges off the floor; turn and fold the gown inside out; discard it in a
contaminated linen container; then wash her hands again.
12. B. According
to the Centers for Disease Control (CDC), blood-to-blood contact occurs most
commonly when a health care worker attempts to cap a used needle. Therefore,
used needles should never be recapped; instead they should be inserted in a
specially designed puncture resistant, labeled container. Wearing gloves is not
always necessary when administering an I.M. injection. Enteric precautions
prevent the transfer of pathogens via feces.
13. A. Nurses
and other health care professionals previously believed that massaging a
reddened area with lotion would promote venous return and reduce edema to the
area. However, research has shown that massage only increases the likelihood of
cellular ischemia and necrosis to the area.
14. B. Before a
blood transfusion is performed, the blood of the donor and recipient must be
checked for compatibility. This is done by blood typing (a test that determines
a person’s blood type) and cross-matching (a procedure that determines the
compatibility of the donor’s and recipient’s blood after the blood types has
been matched). If the blood specimens are incompatible, hemolysis and
antigen-antibody reactions will occur.
15. A. Platelets
are disk-shaped cells that are essential for blood coagulation. A platelet
count determines the number of thrombocytes in blood available for promoting
hemostasis and assisting with blood coagulation after injury. It also is used
to evaluate the patient’s potential for bleeding; however, this is not its
primary purpose. The normal count ranges from 150,000 to 350,000/mm3.
A count of 100,000/mm3 or less indicates a potential for bleeding;
count of less than 20,000/mm3 is associated with spontaneous
bleeding.
16. D.
Leukocytosis is any transient increase in the number of white blood cells
(leukocytes) in the blood. Normal WBC counts range from 5,000 to 10,000/mm3.
Thus, a count of 25,000/mm3 indicates leukocytosis.
17. A. Fatigue,
muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an
inadequate potassium level), which is a potential side effect of diuretic
therapy. The physician usually orders supplemental potassium to prevent
hypokalemia in patients receiving diuretics. Anorexia is another symptom of
hypokalemia. Dysphagia means difficulty swallowing.
18. A. Pregnancy
or suspected pregnancy is the only contraindication for a chest X-ray. However,
if a chest X-ray is necessary, the patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry, metallic objects, and buttons would
interfere with the X-ray and thus should not be worn above the waist. A signed
consent is not required because a chest X-ray is not an invasive examination.
Eating, drinking and medications are allowed because the X-ray is of the chest,
not the abdominal region.
19. A. Obtaining
a sputum specimen early in this morning ensures an adequate supply of bacteria
for culturing and decreases the risk of contamination from food or medication.
20. A. Initial
sensitivity to penicillin is commonly manifested by a skin rash, even in
individuals who have not been allergic to it previously. Because of the danger
of anaphylactic shock, he nurse should withhold the drug and notify the
physician, who may choose to substitute another drug. Administering an
antihistamine is a dependent nursing intervention that requires a written
physician’s order. Although applying corn starch to the rash may relieve
discomfort, it is not the nurse’s top priority in such a potentially
life-threatening situation.
21. D. The
Z-track method is an I.M. injection technique in which the patient’s skin is
pulled in such a way that the needle track is sealed off after the injection.
This procedure seals medication deep into the muscle, thereby minimizing skin
staining and irritation. Rubbing the injection site is contraindicated because
it may cause the medication to extravasate into the skin.
22. D. The
vastus lateralis, a long, thick muscle that extends the full length of the
thigh, is viewed by many clinicians as the site of choice for I.M. injections
because it has relatively few major nerves and blood vessels. The middle third
of the muscle is recommended as the injection site. The patient can be in a
supine or sitting position for an injection into this site.
23. A. The
mid-deltoid injection site can accommodate only 1 ml or less of medication because
of its size and location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve).
24. D. A 25G,
5/8” needle is the recommended size for insulin injection because insulin is
administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for
I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½”
needle is usually used for adult I.M. injections, which are typically
administered in the vastus lateralis or ventrogluteal site.
25. D. Because
an intradermal injection does not penetrate deeply into the skin, a small-bore
25G needle is recommended. This type of injection is used primarily to
administer antigens to evaluate reactions for allergy or sensitivity studies. A
20G needle is usually used for I.M. injections of oil-based medications; a 22G
needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G
needle, for subcutaneous insulin injections.
26. A.
Parenteral penicillin can be administered I.M. or added to a solution and given
I.V. It cannot be administered subcutaneously or intradermally.
27. D. gr 10 x
60mg/gr 1 = 600 mg
28. C. 100ml/60
min X 15 gtt/ 1 ml = 25 gtt/minute
29. A.
Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a
hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In
this reaction, antibodies in the recipient’s plasma combine rapidly with donor
RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial
system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities. Chest pain and urticaria may be symptoms of impending
anaphylaxis. Distended neck veins are an indication of hypervolemia.
30. C. In real
failure, the kidney loses their ability to effectively eliminate wastes and
fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids
may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration
are conditions for which fluids should be encouraged.
31. D.
Phlebitis, the inflammation of a vein, can be caused by chemical irritants
(I.V. solutions or medications), mechanical irritants (the needle or catheter
used during venipuncture or cannulation), or a localized allergic reaction to
the needle or catheter. Signs and symptoms of phlebitis include pain or
discomfort, edema and heat at the I.V. insertion site, and a red streak going
up the arm or leg from the I.V. insertion site.
32. D. Return
demonstration provides the most certain evidence for evaluating the
effectiveness of patient teaching.
33. D. Capsules,
enteric-coated tablets, and most extended duration or sustained release
products should not be dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid reasons, and altering
them destroys their purpose. The nurse should seek an alternate physician’s
order when an ordered medication is inappropriate for delivery by tube.
34. D. A
drug-allergy is an adverse reaction resulting from an immunologic response
following a previous sensitizing exposure to the drug. The reaction can range
from a rash or hives to anaphylactic shock. Tolerance to a drug means
that the patient experiences a decreasing physiologic response to repeated
administration of the drug in the same dosage. Idiosyncrasy is an
individual’s unique hypersensitivity to a drug, food, or other substance; it
appears to be genetically determined. Synergism, is a drug interaction
in which the sum of the drug’s combined effects is greater than that of their
separate effects.
35. D. A
hemoglobin and hematocrit count would be ordered by the physician if bleeding
were suspected. The other answers are appropriate nursing interventions for a
patient who has undergone femoral arteriography.
36. A. Coughing,
a protective response that clears the respiratory tract of irritants, usually
is involuntary; however it can be voluntary, as when a patient is taught to
perform coughing exercises. An antitussive drug inhibits coughing. Splinting
the abdomen supports the abdominal muscles when a patient coughs.
37. C. In an
infected patient, shivering results from the body’s attempt to increase heat
production and the production of neutrophils and phagocytotic action through
increased skeletal muscle tension and contractions. Initial vasoconstriction
may cause skin to feel cold to the touch. Applying additional bed clothes helps
to equalize the body temperature and stop the chills. Attempts to cool the body
result in further shivering, increased metabloism, and thus increased heat
production.
38. D. A
clinical nurse specialist must have completed a master’s degree in a clinical
specialty and be a registered professional nurse. The National League of
Nursing accredits educational programs in nursing and provides a testing
service to evaluate student nursing competence but it does not certify nurses.
The American Nurses Association identifies requirements for certification and
offers examinations for certification in many areas of nursing., such as
medical surgical nursing. These certification (credentialing) demonstrates that
the nurse has the knowledge and the ability to provide high quality nursing
care in the area of her certification. A graduate of an associate degree
program is not a clinical nurse specialist: however, she is prepared to provide
bed side nursing with a high degree of knowledge and skill. She must
successfully complete the licensing examination to become a registered
professional nurse.
39. D.
Microorganisms usually do not grow in an acidic environment.
40. D. Bile
colors the stool brown. Any inflammation or obstruction that impairs bile flow
will affect the stool pigment, yielding light, clay-colored stool. Upper GI
bleeding results in black or tarry stool. Constipation is characterized by
small, hard masses. Many medications and foods will discolor stool – for
example, drugs containing iron turn stool black.; beets turn stool red.
41. D. In the
evaluation step of the nursing process, the nurse must decide whether the
patient has achieved the expected outcome that was identified in the planning
phase.
42. A. The main
sources of vitamin A are yellow and green vegetables (such as carrots, sweet
potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow
fruits (such as apricots, and cantaloupe). Animal sources include liver,
kidneys, cream, butter, and egg yolks.
43. D. Maintaing
the drainage tubing and collection bag level with the patient’s bladder could
result in reflux of urine into the kidney. Irrigating the bladder with
Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed
by a physician.
44. D. The ELISA
test of venous blood is used to assess blood and potential blood donors to
human immunodeficiency virus (HIV). A positive ELISA test combined with various
signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
45. A. Total
Parenteral Nutrition (TPN) requires the use of a large vessel, such as the
subclavian or jugular vein, to ensure rapid dilution of the solution and
thereby prevent complications, such as hyperglycemia. The brachial and femoral
veins usually are contraindicated because they pose an increased risk of
thrombophlebitis.
46. D. Studies
have shown that showering with an antiseptic soap before surgery is the most
effective method of removing microorganisms from the skin. Shaving the site of
the intended surgery might cause breaks in the skin, thereby increasing the
risk of infection; however, if indicated, shaving, should be done immediately
before surgery, not the day before. A topical antiseptic would not remove
microorganisms and would be beneficial only after proper cleaning and rinsing.
Tub bathing might transfer organisms to another body site rather than rinse
them away.
47. C. The leg
muscles are the strongest muscles in the body and should bear the greatest
stress when lifting. Muscles of the abdomen, back, and upper arms may be easily
injured.
48. C. The
factors, known as Virchow’s triad, collectively predispose a patient to
thromboplebitis; impaired venous return to the heart, blood hypercoagulability,
and injury to a blood vessel wall. Increased partial thromboplastin time
indicates a prolonged bleeding time during fibrin clot formation, commonly the
result of anticoagulant (heparin) therapy. Arterial blood disorders (such as
pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede
venous return of injure vessel walls.
49. A. Because
of restricted respiratory movement, a recumbent, immobilize patient is at
particular risk for respiratory acidosis from poor gas exchange; atelectasis
from reduced surfactant and accumulated mucus in the bronchioles, and
hypostatic pneumonia from bacterial growth caused by stasis of mucus
secretions.
50. B. The
immobilized patient commonly suffers from urine retention caused by decreased
muscle tone in the perineum. This leads to bladder distention and urine
stagnation, which provide an excellent medium for bacterial growth leading to
infection. Immobility also results in more alkaline urine with excessive
amounts of calcium, sodium and phosphate, a gradual decrease in urine
production, and an increased specific gravity.
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