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MCQ. Medical Surgical Nursing

1. Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be:

1. “Pain will become less each day.”
2.  “This is a normal reaction after surgery.”
3. “With a pillow, apply pressure against the incision.”
4.  “I will give you the pain medication the physician ordered.”

2. The nurse needs to carefully assess the complaint of pain of the elderly because older people

1. are expected to experience chronic pain
2. have a decreased pain threshold
3. experience reduced sensory perception
4. have altered mental function

3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best

1. The patient is having an allergic reaction to the drug.
2. The patient needs a higher dose of this drug
3. This is normal side-effect of AtSO4
4. The patient is anxious about upcoming surgery

4. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?

1. Put the client in modified Trendelenberg’s position.
2. Administer oxygen at 100%.
3. Monitor urine output every hour.
4. Administer Demerol 50mg IM q4h

5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?

1. “Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?”
2. “Mr, Pablo, you must be so worried, I’ll leave you alone with your thoughts.
3. “Mr. Pablo, you’ll wear out the hospital floors and yourself at this rate.”
4.  “Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?”

6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take?

1. Call the physician immediately.
2. Administer the prescribed antiemetic.
3. Check the patency of the nasogastric tube for any obstruction.
4. Change the patient’s position.

7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to:

1. Reassure him that the nurses will not hurt him
2. Let him perform his own activities of daily living
3. Handle him gently when assisting with required care
4. Complete A.M. care quickly as possible when necessary

8. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate?

1. Notify his physician.
2. Take his vital signs again in 15 minutes.
3.  Take his vital signs again in an hour.
4. Place the patient in shock position.

9. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

1.  Reactive pupils
2. A depressed fontanel
3.  Bleeding from ears
4.  An elevated temperature

10. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?

1. “I exercise every other day.”
2. “My father died of Myasthenia Gravis.”
3. “My cholesterol is 180.”
4. “I smoke 1 1/2 packs of cigarettes per day.”

11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?

1. It has positive inotropic and negative chronotropic effects
2. The positive inotropic effect will decrease urine output
3. Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
4. Do not give the drug if the apical rate is less than 60 beats per minute.

12. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?

1. Use of stool softeners.
2. Enema administration
3. Gagging while toothbrushing.
4. Lifting heavy objects

13. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

1. take the pulse rate once a day, in the morning upon awakening
2. may be allowed to use electrical appliances
3. have regular follow up care
4. may engage in contact sports

14. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching?

1. “When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.”
2. “Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.”
3. “Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.”
4. “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved.

15. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food?

1. Whole milk
2. Canned sardines
3. Plain nuts
4. Eggs

16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate?

1. Apply a heating pad to the involved site.
2. Elevate the client’s legs 90 degrees.
3. Instruct the client about the need for bed rest.
4. Provide active range-of-motion exercises to both legs at least twice every shift.

17. A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client?

1. It dissolves existing thrombi.
2. It prevents conversion of factors that are needed in the formation of clots.
3. It inactivates thrombin that forms and dissolves existing thrombi.
4. It interferes with vitamin K absorption.

18. The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? :

1. Dyspnea on exertion
2. Foamy, blood-tinged sputum
3. Wheezing sound on inspiration
4. Cough or change in a chronic cough

19. Which is the most relevant knowledge about oxygen administration to a client with COPD?

1. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
2. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
3. Oxygen is administered best using a non-rebreathing mask
4. Blood gases are monitored using a pulse oximeter.

20. When suctioning mucus from a client’s lungs, which nursing action would be least appropriate?

1. Lubricate the catheter tip with sterile saline before insertion.
2. Use sterile technique with a two-gloved approach
3. Suction until the client indicates to stop or no longer than 20 second
4. Hyperoxygenate the client before and after suctioning

21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to

1. Cause less irritation to the gastrointestinal tract
2. Destroy resistant organisms and promote proper blood levels of the drugs
3. Gain a more rapid systemic effect
4. Delay resistance and increase the tuberculostatic effect

22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler’s position on either his right
side or on his back to

1. Reduce incisional pain.
2. Facilitate ventilation of the left lung.
3. Equalize pressure in the pleural space.
4. Increase venous return

23. A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT

1. Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
2. Inhale slowly through the mouth as the canister is pressed down
3. Hold his breath for about 10 seconds before exhaling
4. Slowly breath out through the mouth with pursed lips after inhaling the drug.

24. A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse’s highest priority of information would be

1. Food and fluids will be withheld for at least 2 hours.
2. Warm saline gargles will be done q 2h.
3. Coughing and deep-breathing exercises will be done q2h.
4.  Only ice chips and cold liquids will be allowed initially.

25. The nurse enters the room of a client with chronic obstructive pulmonary disease. The client’s nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action?

1. Take heart rate and blood pressure.
2. Call the physician.
3. Lower the oxygen rate.
4. Position the client in a Fowler’s position.

26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?

1. Fluid volume deficit
2. Decreased tissue perfusion.
3. Impaired gas exchange.
4. Risk for infection

27. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity?

1. large thighs and upper arms
2. pendulous abdomen and large hips
3. abdominal striae and ankle enlargement
4. posterior neck fat pad and thin extremities

28. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy?

1. “I should limit my potassium intake because hyperkalemia is a side-effect of this drug.”
2. “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
3. “This medicine will protect me from getting any colds or infection.”
4. “My incision will heal much faster because of this drug.”

29. A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential for the nurse to make first?

1. Pupil reaction
2. Hand grips
3. Blood pressure
4. Blood glucose

30. The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to:

1. Encourage the guest to eat some baked macaroni
2. Call the guest’s personal physician
3. Offer the guest a cup of coffee
4. Give the guest a glass of orange juice

31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be:

1. “The medication will limit thyroid hormone secretion.”
2. “The medication limit synthesis of the thyroid hormones.”
3. “The medication will block the cardiovascular symptoms of Grave’s disease.”
4. “The medication will increase the synthesis of thyroid hormones.”

32. During the first 24 hours after thyroid surgery, the nurse should include in her care:

1. Checking the back and sides of the operative dressing
2. Supporting the head during mild range of motion exercise
3. Encouraging the client to ventilate her feelings about the surgery
4. Advising the client that she can resume her normal activities immediately

33. On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops:

1. Intolerance to heat
2. Dry skin and fatigue
3. Progressive weight gain
4. Insomnia and excitability

34. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?

1. Lipodystrophy can result and is extremely painful
2. Poor rotation technique can cause superficial hemorrhaging
3. Lipodystrophic areas can result, causing erratic insulin absorption rates from these
4. Injection sites can never be reused

35. Which of the following would be inappropriate to include in a diabetic teaching plan?

1. Change position hourly to increase circulation
2. Inspect feet and legs daily for any changes
3. Keep legs elevated on 2 pillows while sleeping
4. Keep the insulin not in use in the refrigerator

36. Included in the plan of care for the immediate post-gastroscopy period will be:

1. Maintain NGT to intermittent suction
2. Assess gag reflex prior to administration of fluids
3. Assess for pain and medicate as ordered
4. Measure abdominal girth every 4 hours

37. Which description of pain would be most characteristic of a duodenal ulcer?

1. Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
2. RUQ pain that increases after meal
3. Sharp pain in the epigastric area that radiates to the right shoulder
4. A sensation of painful pressure in the midsternal area

38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:

1. Reposition the NGT by advancing it gently NSS
2. Notify the MD of your findings
3. Irrigate the NGT with 50 cc of sterile
4. Discontinue the low-intermittent suction

39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care?

1. Sit upright for at least 30 minutes after meals
2. Take only sips of H2O between bites of solid food
3. Eat small meals every 2-3 hours
4. Reduce the amount of simple carbohydrate in the diet

40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data?

1. Treatment will include Ranitidine and Antibiotics
2. No treatment is necessary at this time
3. This result indicates gastric cancer caused by the organism
4. Surgical treatment is necessary

41. What instructions should the client be given before undergoing a paracentesis?

1. NPO 12 hours before procedure
2. Empty bladder before procedure
3. Strict bed rest following procedure
4. Empty bowel before procedure

42. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet?

1. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
2. “The liver heals better with a high carbohydrates diet rather than protein.”
3. “Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
4. “Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”

43. Which of the drug of choice for pain controls the patient with acute pancreatitis?

1. Morphine
2. NSAIDS
3. Meperidine
4. Codeine

44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is:

1. encouraging the client to take adequate deep breaths by mouth
2. encouraging the client to cough and deep breathe
3. changing the dressing at least BID
4. irrigate the T-tube frequently

45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:

1. Deflate the esophageal balloon
2. Monitor VS
3. Encourage him to take deep breaths
4. Notify the MD

46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease?

1. Chrons disease
2. Ulcerative colitis
3. Diverticulitis
4. Peritonitis

47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:

1. Give laxative the night before and a cleansing enema in the morning before the test
2. Render an oil retention enema and give laxative the night before
3. Instruct the client to swallow 6 radiopaque tablets the evening before the study
4. Place the client on CBR a day before the study

48. The client has a good understanding of the means to reduce the chances of colon cancer when he states:

1. “I will exercise daily.”
2. “I will include more red meat in my diet.”
3. “I will have an annual chest x-ray.”
4.  “I will include more fresh fruits and vegetables in my diet.”

49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to

1. Cover the wound with sterile, moist saline dressing
2. Approximate the wound edges with tapes
3. Irrigate the wound with sterile saline
4. Hold the abdominal contents in place with a sterile gloved hand

50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to

1. Strain all urine.
2. Ambulate.
3. Remain on bed rest.
4. Ask for medications to relax him.

Answers and Rationales

1. Answer: (C) “With a pillow, apply pressure against the incision.” Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.
2. Answer: (C) experience reduced sensory perception . Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.
3. Answer: (C) This is normal side-effect of AtSO4. Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
4. Answer: (D) Administer Demerol 50mg IM q4h. Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.
5. Answer: (D) “Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?”. The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.
6. Answer: (C) Check the patency of the nasogastric tube for any obstruction. Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.
7. Answer: (C) Handle him gently when assisting with required care . Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently.
8. Answer: (B) Take his vital signs again in 15 minutes. Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring.
9. Answer: (C) Bleeding from ears . The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.
10. Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.” Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.
11. Answer: (B) The positive inotropic effect will decrease urine output . Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output.
12. Answer: (A) Use of stool softeners. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.
13. Answer: (D) may engage in contact sports . The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
14. Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention.
15. Answer: (B) Canned sardines . Canned foods are generally rich in sodium content as salt is used as the main preservative.
16. Answer: (C) Instruct the client about the need for bed rest. In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
17. Answer: (B) It prevents conversion of factors that are needed in the formation of clots. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
18. Answer: (D) Cough or change in a chronic cough .Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.
19. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive.
20. Answer: (C) Suction until the client indicates to stop or no longer than 20 second .One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.
21. Answer: (D) Delay resistance and increase the tuberculostatic effect . Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.
22. Answer: (B) Facilitate ventilation of the left lung.  Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
23. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.
24. Answer: (A) Food and fluids will be withheld for at least 2 hours.  Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
25. Answer: (C) Lower the oxygen rate.  The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR.
26. Answer: (C) Impaired gas exchange.  Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.
27. Answer: (D) posterior neck fat pad and thin extremities .“ Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome.
28. Answer: (B) “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”  The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis
29. Answer: (C) Blood pressure . Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
30. Answer: (D) Give the guest a glass of orange juice . In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.
31. Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.” Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.
32. Answer: (A) Checking the back and sides of the operative dressing . Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.
33. Answer: (C) Progressive weight gain . Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
34. Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these . Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.
35. Answer: (C) Keep legs elevated on 2 pillows while sleeping . The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
36. Answer: (B) Assess gag reflex prior to administration of fluids . The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.
37. Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake . Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.
38. Answer: (B) Notify the MD of your findings . The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.
39. Answer: (A) Sit upright for at least 30 minutes after meals  . The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.
40. Answer: (A) Treatment will include Ranitidine and Antibiotics . One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
41. Answer: (B) Empty bladder before procedure . Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.
42. Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”  The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.
43. Answer: (C) Meperidine . Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
44. Answer: (B) encouraging the client to cough and deep breathe . Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.
45. Answer: (A) Deflate the esophageal balloon . When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction
46. Answer: (B) Ulcerative colitis . Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.
47. Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test .Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.
48. Answer: (D) “I will include more fresh fruits and vegetables in my diet.”  Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.
49. Answer: (A) Cover the wound with sterile, moist saline dressing . Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.
50. Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.

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Nursing Education

Nursing Education

Definition:

*        Education is that which makes a man of good character and useful to the society. (Yajnavaikya).

*        Education is the manifestation of divine perfection already existing in man. (Viveka.nanda).

*         Education is the all-round drawing of the best in child and man-body-mind and spirit. (M.K. Gandhi).

Nursing education

*        Nursing education is the professional education for the preparation of nurses to enable them to render professional nursing care to people of all ages, in all phases of health and illness, in a variety of settings.

3.A BRIEF HISTORY OF NURSING EDUCATION:

3.1 NURSING EDUCATION WORLDWIDE:

3.1.1. EUROPEAN SCOOLS OF NURSING:

Early nurses did not receive formal training specifically designed to prepare them to care for the sick. The school of Kaiserwerth was one of the programs which were established to train women to care for the sick and poor. The La Source program was founded in 1859 in Germany to prepare lay women to care for sick in their homes. The theory consisted of an hour class held daily for five months, for a total of 120 hours. The students studied anatomy, physiology, hygiene, pathology and nursing procedures.

       At the completion of program the student was given an oral examination. The students wore no uniforms and were not called nurses. The La source programme later developed into three year programme. The first nine months considered a probationary period after passing a comprehensive examination; students became regular students and completed the three year programme.

Florence Nightingale was the first to envision nursing education as a preparation for nursing practice. She advocated the establishment of nursing education in an endowed school, where the chief purpose was education rather than service. Nightingale firmly believed that nursing was a profession based on fundamental principles, and that it was distinct from medical profession. She wanted nurse to be educated in a programme of systematic instruction, which included both theory and nursing skills. Nightingale, as a product of Victorian England was very concerned about the character and morality of nurses; both had to be beyond reproach.

3.1.2. THE NIGHTINGALE SCHOOL FOR NURSES:

Florence Nightingale advocated nursing as both an art and a science. She strongly believed that the focus of the training school should be nursing education rather than nursing service. She felt the curriculum should be flexible and stress compassion and empathy for the patient. She insisted that the patient was to be treated as a whole person and not as a disease entity. She also realized that clinical practice and theory must be con-elated to ensure quality education. Using monies from the Nightingale fund; a building to house nursing students was purchased. St.Thomas hospital, London was selected for the clinical learning experiences. It was started in June 1860, with 15 probationers selected by Miss. Nightingale.

The purpose of the school was to train the probationers as hospital and district health nurses. To attract educated young women there were two classes of nurses. Special or paying students paid fees and worked as staff for two years after their probationary-training; while other students did not pay fees and worked for three years after their training. At the completion of their time they become certified nurses.

The Nightingale School is considered the first "modem" school of nursing and the beginning of nursing as an organized profession. The programme was one year w length. Evaluation and testing was done by the school matron. Graduates of the schools were not licensed as they are today. In fact, nightingale did not approve of licensing examinations because she felt there were no outside groups capable of testing the knowledge of nurses. Graduate of the Nightingale school were later head nurses in Scotland, Germany, Norway, Sweden, Canada, the United States, South Africa, India and Australia.

3.1.3.  EARLY NURSING EDUCATION IN THE UNITED STATES:

During the first pan of nineteenth century, the only organized preparation of nurses was in catholic sisterhoods, training was apprenticeship and restricted to members of the order. In 1839, the nurse society of Philadelphia, under the direction of Dr.Joseph Warrington, organized a school of nursing which was patent after the work of Elizabeth fry in England. In 1861 the women's hospital of Philadelphia, offered a six month's design to appeal higher class of young women. The courses included medical surgical nursing Materia Medica: and dietetics a diploma was awarded upon the completion of programme. Dr.Mary Zakrzewska, a obstetrician attempted to establish a training school at the new Inland hospital for women and children in Boston, Massachusetts, in 1861.

3.1.4.  EARLY PROGRAMMES:

Three schools-Bellevue Hospital training school in New York, Massachusetts, hospital training school in Boston, and the Connecticut training school in new heaven were opened in America during 1873. The schools greatly influenced the development of nursing education.

Hours of duty were long and students had one afternoon off every two weeks. Nurses often slept in rooms located between patient rooms as students were expected to attend to patient during the night. Student nurses lived in a hospital dormitory or nurses homes. Obedience was expected and discipline was severe.

3.1.5.  BELLEVUE HOSPITAL SCHOOL OF NURSING:

Women involved in the reform movement turned their interest and efforts toward the improvement of the hospitals by improving the nursing care within the existing institutions. One of such group was the New York state charities aid association, of which Bellevue Hospital visiting committee was an integral part.

The nightingale system was followed in New York; it was called the Bellevue system. The training programme was one year in length, but students were required to remain for second year doing service. Duties in the second year included private duty nursing in the patient home and head nursing. In 1876, the school published the first nursing manual.

3.1.6.  MASSACHUSETTS GENERAL HOSPITAL:

The training school of the Massachusetts General Hospital in Boston was opened on November 1^st, 1873 with a class of six students. Because this was the first school to attempt a formalized instructional program. It is recognized as one of the pioneering schools in nursing education.

3.1.7.  THE CONNECTICUT TRAINING SCHOOL:

At the request of the medical staff of new heaven hospital, The Connecticut training school was established in 1873\ht school was totally independent of the hospital. This may have brought about the great success. The school quickly grew in size and its graduates become superintendents in other school of nursing. Doctors and nurses collaborated to write comprehensive nursing textbook. The new heaven manual of nursing which was published in 1879 the text was used by nearly all the nursing schools being organized throughout the United States. The school was one of the institutions to obtain university affiliation and endowment. Today it is the Yale university school of nursing.

3.1.8.  THE DEVELOPMENT OF NURSING EDUCATION:

IN 1879 there were eleven training schools in United States in 1885the reported number of rose to thirty four. The rapid expansion of scientific medicine necessitated more hospitals and thus more nurses.

3.1.9.  EARLY TRENDS:

In 1895 the American society of superintendents of training school of nurses was organized. This group was concerned with improvement of curricula and standard of admission in 1912 the association changed its name to the national league of nursing education. In 1917 a standard curriculum for schools of nursing was published which outlined the curriculum for a three year course.

The curriculum guide for schools of nursing which was third edition was published in 1937. It established guidelines for curriculum planning and discussed tjie need for clinical instruction to augment the theoretical courses. It also refereed to professional education and collegiate education for nurses. In 1907, the American hospital association determined there were three classifications of nurses:

1.      Administrators and Educators,

2.      Beside nurses, and

3.      Attendant of subsidiary nurse.

The AHA believed all three groups needed special training but that nurses in the first two classifications should be examined and licensed by state members and the third group were to be supervised by the administrative and beside nurses.

3.1.10.            THE WINSLOW-GOLDMARK REPORT:

When World War I began more nurses were needed. Many schools of nursing waived their admission in order to recruit as many students as possible. The Rockefeller Foundation became interested in health care and decided to fund the committee. For the study of nursing education Dr C. A. Winslow, an expert in public health was the chairman of committee but his secretary, Josephine gold mark was responsible for study. In its 1923 report, a committee made a number of recommendations which had great influence on the development of nursing education.

The committee further recommended that auxiliary workers be trained to assume duties which did not require the expertise of the graduate nurse. The coinmittee recommended that nursing school affiliate with a college or university and those schools should be funded.

3.1.11.            THE COMMITTEE ON THE GRADING OF SCHOOLS OF NURSING:

In 1925, another committee was developed to continue the study done by wins low and gold mark. Representatives of the national league of nursing education, the American nurses association the national organization for public health nursing, the American medical association and American hospital association comprised the committee on the grading of schools of nursing. The committee was given the tasks of studying the supply and demand of nurses. Analyzing nursing practice and education, and grading the nursing schools. The study took over seven years .The findings of the committee indicated that nursing education was inadequate to prepare nurses who could meet the expectations and needs of the consumers of nursing services. The study led to reform in nursing education.

The committee on accreditation developed standards for the evaluation of nursing schools in 1941 the first list accredited schools was published.

3.1.12. THE BROWN REPORT:

In 1944, a postwar planning group the national nursing planning committee was established to develop professional objectives and determine the areas which required study and research. In 1947, Dr. Ester Lucile brown, social, scientist undertook a study of schools of nursing. The study recommended that all existing schools of nursing in the country should get affiliations with universities, and the schools of nursing should have their own budgets. It was recommended that professional nurses should be educated at the baccalaureate level and two year college programs be developed to prepare nurses to relieve nursing shortage. Regional planning for nursing education and service was recommended in order to adequately meet the needs of the community in the future.

3.1.13. FEDERAL FUNDING:

Florence nightingale had stated that nursing schools should be responsible to the public for the quality of work of their graduates. In turn, she felt that nursing education was a responsible of the public and that public funds should support schools of nursing. The standards of nursing education were greatly improved across the country, because in order to obtain federal monies, schools had to meet the requirements developed by the national league of education.

The Nurse Training Act of 1943 provided for the establishment of the Cadet Nurse Coips, post graduate education and refresher courses. In 1964, another Nurse Training act was passed and it provided federal assistance to schools of nursing and nursing students. In 1971 the Nurse Training Act. was expanded to include student aid, research grants, funding for new schools of nursing, capitation, and preparation of nurse specialists. In 1975, appropriations were made for construction grants project grants, institutional support, financial distress, nurse practitioner preparation, traineeships, and student loans.

CURRENT   NURSING   EDUCATION   PROGRAMMES   IN   UNITED

KINGDOM:

Students wishing to train as a nurse undertake either a pre-registration diploma or degree at university. This is normally a three year programme designed to combine classroom theory -with real, practical -nursing experience in hospital or community settings. There is also an accelerated Diploma for graduates who already hold a health related degree.

Diploma and degree courses are run at different academic levels, however there is an element of overlap, as diploma level students can transfer to degree courses or can opt to come back and 'top up' their diploma in nursing to a degree at a later stage.

o   Post basic nursing program is provided for the diploma nurses,

o   Master's level nursing program are developing rapidly.

CURRENT NURSING EDUCATION PROGRAMS IN JAPAN:

There are three types of nursing programs in japan,

o   Baccalaureate

o   Junior college and

o   Diploma nursing program

Diploma to baccalaureate programs for diploma nurses.

Diploma to master in nursing program for diploma nurses is emerging.

Other continuing nurse education program includes,

Certified nurse specialist in

■       Cancer

■       Women's health

■       Child health

■       Gerontology

■       Psychiatry

■       Community health

■       Emergency,  critical care,hospice care,  infection control,  diabetes nursing.

CURRENT NURSING EDUCATION STATUS IN RUSSIA:

Level 1 nurse:

3years of training after 12* standard.    

Level 2 nurse:

Considered as nurse educator, additionally 1.5 years of training is provided.      

 

Level 3 nurse:

4.5 years of university level nursing is provided. After graduation they were considered as nurse managers.

CURRENT NURSING EDUCATION PROGRAMMES IN AUSTRALIA:

DIPLOMA OF NURSING

            Duration 1.5 Years

Note: one year of study is equivalent to not less than 36 weeks of instruction.

BACHELOR OF NURSING

            Duration 3 years full-time

MASTER OF NURSING (Management / Practice)

            Duration 1 year full-time       

MASTER OF NURSING (Clinical Education)

            Duration 1 year full-time study

MASTER OF CLINICAL NURSING

Duration 1.5 Years full-time

MASTER OF NURSING LEADERSHIP

            Duration-1 year full-time

CURRENT NURSING EDUCATION PROGRAMMES IN CANADA:

*        PERSONAL SUPPORT WORKER

*        HEALTH CARE AND NURSING ASSISTANT DIPLOMA

*        NURSING ASSISSTANT AND COMMUNICATION

*        NURSINF LICENSURE PREPARATION

*        HEALTH CARE ASSISSTANT CERTIFICATE

*        NURSING UNIT CLERK

*        RESIDENT CARE ATTENDANT

*        NURSING ATTENDANT HEALTH CARE AIDE

*        VETERINARY NURSING

*        PRACTICAL NURSING

*        DIPLIMA IN PSYCHIATRIC NURSING

*        PEDIATRIC NURSING CERTIFICATE

*        ONCHOLOGY NURSING CERTIFICATE

*        CARDIOLOGY NURSING CERTIFICATE

*        MATERNAL & NEW BORN NURSING CERTIFICATE

*        REHABILITATION CARE NURSING CERTIFICATE

*        LONG TERM CARE NURSING CERTIFICATE

*        FORENSIC NURSING CERTIFICATE

*        DOCTOR OF NURSING PRACTICE

*        MSN

*        PSYCHIATRIC CLINICAL NURSE SPECIALIST

*        LEGAL ETHICAL ISSUES NURSING CERTIFICATE

*        FNP

*        ACUTE CARE NURSE SPECIALIST

CURRENT NURSING EDUCATION PROGRAMMES IN UNITED

STATES:

LPN/LVN:

Licensed practical nurse (LPN) or Licensed vocational nurse: to earn LPN/LVN state administered nursing examination should be passed. It involves one year training at a hospital, vocational school, or community college. Eligibility any degree.

LPN-TO-ASSOCIATE's

This programme is designed for LPN's who want to earn a degree that will enable them to sit for NCLEX Examination.

LPNtoBSN:

It allows the LPN to become BSN in just two year degree programme.

ASSOCIATE OF SCIENCE IN NURSING: (ASN)

It is a two year degree programme. It is entry point for technical nursing practice. ASN allows a student to become a Registered Nurse (RN) For ASN's it is the stepping stone to a BSN.

RN to BSN:

This programme is designed for ASN's to get BSN degree. This programme is also known as bridge programme.

Second degree BSN:

It is designed for non-nurses who have Bachelor degree in non nursing fields. Duration of course is two years. Entry is through entrance exam.

Accelerated degree BSN:

A variation of the Second degree BSN is the Accelerated degree BSN. Here it is shorter in duration of study i.e. only 12 months of course. Entry is through entrance exam.

MSN:

It is an 18-24 month programme that allows a nurse to specialize in any particular area, such as area of advanced clinical nursing or research. Requirements include a BSN, a RN license and some period of clinical work experience.

AND to MSN:

This programme is for the AND's who want to earn an MSN immediately after earning BSN.

Direct entry MSN:

Direct entry MSN, sometimes called "graduate entry", or masters entry programmes, are designed for non nurses who hold bachelors degree in non nursing fields. The duration of study is three years. Course of study involves under graduate nursing subjects, it also combines preparation for RN licensure with advances training in master's specialty area. First year is being devoted for entry-level nursing coursework and last two years for master* s-level study.

Post master's certificate programmes:

Post master's certificate programmes are designed for nurses who already have a Master of Science degree in nursing who wish to qualify to sit for one of the certification exams or to expand into a new area of specialization.

Post-certificate Master's:

In the past, many states allowed RNs to earn certification as nurse anesthetist (CRNA), nurse practitioner (NP), or nurse midwifes (CNM) without earning a Master's degree. These requirements have generally changed, and some schools offer programs that allow these certified nurses to earn their master's degrees while earning credit for their past educational and work experience. More and more states and employers are now requiring Master's degrees to allow these certified non-master's nurses to practice. In some ways these programs are parallel to the RN to BSN programmes, which don't qualify you for any new certifications and licenses, but which add to your professional credentials and make you more employable.

Doctoral programmes:

In a doctoral programme everyone receives training in research methods (including statistics and data analysis), the history and philosophy of nursing science, and in leadership skills.

Doctor of nursing programme:

ND programmes usually require 3-5 years of full-time study. The doctor of nursing degree generally builds on the role of the advanced practice nurse and is more focused on developing advanced practice nurse specialist skills. The goal is to prepare leaders who can affect change through system redesign and evidenced-based decision making in a variety of clinical, organizational and educational settings.

Doctor of Nursing Practice Programs:

DNP programmes usually require 3 years of full-time study and emphasize clinical practice-oriented leadership development. The goal is to prepare graduates for leadership positions in research, clinical care delivery, patient outcomes and system management. Graduates will be experts managing the complex balance between quality of care, access and fiscal responsibilities.

Doctor of Nursing Science:

Graduates of a DNSc programme are prepared as nurse scientists with the investigative skills of a researcher and the clinical and leadership skills necessary to influence the health care system. Health outcomes measurement, health care economics, statistical analysis and informatics are common focus areas. A clinical defense and dissertation are common requirements.

Doctor of Philosophy Programmes:

PhD programmes prepare nurse scholars and researchers who will contribute to the growth of nursing science through scholarly research that advances the theoretical foundation of nursing practice and health care delivery. Graduates will be qualified to engage in all dimensions of professional and scholarly life, including the conduct of scholarly inquiry, leadership in health care delivery systems and public policy formation.

MSN/PhD Dual Degree:

The MSN/PhD Dual Degree programme is for highly qualified nurses with a bachelor's degree in nursing who are interested in an intensive, accelerated program simultaneously offering master's preparation and advanced research training at the doctoral level. A typical program takes five years to complete.

A ccelerated BSN to PhD:

These relatively rare programs are focused on students who have definite plans for being a researcher or teacher of nursing in your future. The programs efficiently take you through a BSN, to an MSN, PhD in nursing.

JOINT DEGREE PROGRAMS:

MSN/MPH:

MSN/MBA:

MSN/MSHA:

32. NURSING EDUCATION IN INDIA:

In the past the progress of nursing in India has been hindered by many difficulties such as low state of women, the system of Pardah among Muslim women, caste system among Hindus, illiteracy, poverty, political unrest, etc. Since independence in 1947, many changes have taken place and attitude toward nursing is still changing.

Modem nursing education started on the basic of Florence Nightingale work and training plan developed in hospital school of Nursing in London, it is hard to realize that recognized preparation for modern nursing education began with the establishment of Nightingale school of nursing in London.

Florence Nightingale is created with rounding ordinary nursing and creating the first educational system for nurses. After hospital came into existence in Western Europe and prior to the influence of Florence Nightingale, hospital care was given by women such as prisoners.

Miss Nightingale also believes than the Nursing school should be separate financially and administered from hospitals where the students trained. Nurses were educated under an apprenticeship model of education characterized as a training program in which students could learn by working with and being directed by nurses on a clinical unit. Early apprentice nursing program had no formal classes or textbooks. This model of nursing training questions as early 1500s with recommendation from curriculum committee from NLNE proposed guidelines by establishing norms for nursing education. Thus it signaled an expectation by the nursing communities than preparation of nurses should be an educational rather than apprentice.

3.2.1.  MILITARY NURSING:

It is the earliest type and 1664 the East India Company helped to start a hospital for soldiers at Fort. St. George, Madras. In 1797 a lying hospital was built and 1854 government sanctioned training School for midwives. In 1861 through the (efforts of civilian hospitals) reform in military hospital led to reform in civilian hospitals. This laid foundation for Public Health Nursing.

3.2.2.CIVILIAN HOSPITALS:

Nursing in the Military hospital was of poor quality carried on by male orderliness and the menial staff In 1871 the Governmental General Hospital, Madras, undertook a plan to train nurses. Nurses were brought from England to be in charge and the first six students were those who had previously received their diploma in midwifery. Later this plan was reversed. General training was taken first, followed by a course in midwifery. In 1878 the government invited the Sister of the Community of all saints to come from England and taken over the work of nursing. Their work was appreciated and the need for training nurses was felt. At this time it was difficult to get nurses. There were only a few Anglo-Indians and Indian Christian girls working on mission hospital. The sisters of all saints were the first to establish'a training school for nurses in the hospital. 1891, Bai Kashibat Ganapat, was the first Indian Nurse to come for training.

3.2.3. MISSION HOSPITALS:

Mission hospitals were the first to begin the training of Indian as nurses. In the beginning there was no uniformity of course or educational requirements. About 1907-1910 the North India United Board of Examiners for Mission Hospital was organized and set up rules for admissions and standards of training and conducted a public examination. On 24^th may 1909 the Indian Medical Mission Association granted the nursing Diploma after examining student by Central Board of Nurses training schools in South India.

3.2.4.  DUFFERIN FUND:

Until the late 19^th century there was no women doctors and therefore no care for women except in mission hospitals, this fact was brought to the attention of Queen Victoria. At this time Lady Duffer in was coming out to India with her husband who was on government service. Queen Victoria instructed the Lady Dufferin about the need for medical care for women and children in India and asked her to take a special interest in this problem, lady dufferin wrote to her to get the-financial aid. Thus in 1885, Lady Dufferin was responsible for starting the "National Association for Supplying Medical Aid by women of India''. This is commonly called the "Dufferin Fund' and continues to provide education for women to train nurses and midwives for hospitals and private work.

3.2.5.  TEXT- BOOKS:

One of the handicaps in the development of nursing, schools was the lack of text-books. A beginning has been made in this work and the first text-book for nurses in India was put out by the south India examining board of the nurse's league of Christian medical association of India in 1941.

3.2.6.  NURSING EDUCATION:

Nursing education in India began with very brief periods of training. The basic programme for combined general nursing and midwifery developed rapidly after 1871. The training for general was extended to two years and men for three years before they enter midwifery training. The first four year basic bachelor degree programmes were established in 1946 at RAK (Rajkumari Amrit Kaur) college of nursing in Delhi, and CMC College of Nursing, Vellore.

In 1963 the school of nursing in Trivandrum instituted the first two year post certificate Bachelor degree programme. The first Master's Degree course, a two year post graduate programme, was begun in 1960 at RAK College of Nursing in Delhi.

3.2.7. AUXILIARY NURSING:

A two year programme for the Auxiliary nurse midwife was first established in 1951 at St. Mary's Hospital, Tarn Taran in Punjab state. The practice of the Auxiliary nurse midwife has helped to improve the amount of care given to the patient as well as the health teaching given itb the public.

3.2.8.  REGISTRATION FOR NURSES:

As training for nurses, midwives, and health visitors progressed, the need for legislation to provide basic minimum standards in education and training was felt. In 1926* Madras state formed the first registration council.

3.2.9.  THE INDIAN NURSING COUNCIL:

The Indian nursing council Act was introduced in the constituent Assembly of India m November 1947. It was passed and came into force on December 31, 1947. The purpose of council is to coordinate the activities of the various state registration councils, to set up standards for nursing education and to make sure these standards are carried out.

VARIOUS NURSING COURSES IN INDIA:

ANCILLARY  NURSE/MIDWIFE:

Eligibility criteria: 10^th  std.

Duration of study: 1.5 years.

Examination: Nursing Examination Board

Registration:  R. ANM

REGISTERED NURSE/MIDWIFE:

Eligibility criteria: 12^th std.

Duration of study: 3.5 years.

Examination: Nursing Examination Board

Registration:  R.N, R.M .

B.SC BASIC:

Eligibility criteria: 12^th std. (subjects: physics, chemistry, biology)

Duration of study: 4 years.

Examination: University

Registration:  R.N, R.M

B.SC POST BASIC:

Regular:

Eligibility criteria: 10^th 712^th std. +GNM+2 years Experience

Duration of study: 2 years.

Examination: university.

Registration: Additional

Distance  education:

Eligibility criteria! 10^th /12^th std. +GNM+2 years Experience

Duration of study: 3 years.

Examination: university.

Registration: Additional.

Universities providing distance education in nursing:

IGNOU

1.      B.Sc, Post Basic (Nursing)

            Duration: 3 Years

2.      Certificate programmes:

Certificate in Disaster management, certificate in environmental studies, certificate in food and nutrition, certificate in HIV and family education, certificate in Health care waste management, certificate in maternal and child health care.

3.      Diploma programmes:

Diploma in HIV and Family Education

Diploma in Nutrition and health Education

Diploma in Nursing Administration.

4.      P.G. Diploma programmes:

P.G. Diploma in Disaster management, P.G. Diploma in clinical cardiology, P.G, Diploma in Maternal and child health, P.G. Diploma in hospital and health management.

5.  Master degree programmes:
M.A.Sociology

M.A. Public Administration M.A Rural development M.Sc. Hospital Administration. Duration: 2 years.

6.  Doctorate programmes:
Ph.D. Sociology

Ph.D. Public Administration, Ph.D. in Nursing

Duration: 2 years.

v National institute of health and family welfare:

1. Certificate course - Health and family welfare

v  Vinayaka Missions University:

1.  Certificate course:

In Food and nutrition, disaster management.

2.  Diploma course:

In Acupuncture, Nursing Administration, Food and Nutrition, Child health, Diabetology.

3.  U. G. degree course:

B.A. Public administration, B.Sc, Health care and Hospital management.

4.  P. G. degree course:

M.A.Sociology, M.SW-Master of social work. M.Sc, Applied Psychology, M.Sc, Health care and hospital administration.

5.  Doctorate in nursing

v  Sri Venkateswara University

1.      Certificate course in specialized in cardiolog

v  Kerala University

1.   B.Sc. (Nursing) post basic. Duration: 3 years

2.     P. G. Diploma course:

In Health and hospital administration,

In Clinical child development

In Adolescent and family counseling

3.     M.Phil. In Sociology and Psychology

v  Alagappa University

1.      B.Sc, Nursing, Post basic. Duration: 3 years.

v  Annamalai University

1.   P.G. Diploma in Health Sciences

2.     P. G. Diploma in Public Health

3.     P.G. Diploma in Medical law and ethics

4.     P. G. Diploma in Critical Care Nursing

M.SC NURSING:

Eligibility criteria: B.Sc nursing (+1year exp.) / B.Sc Hons Nursing (+lyear exp.) / Post Basic B.Sc with 55%aggregate marks 

Duration of study: 2 years.

Examination: University

Registration:  Additional

M.PHIL IN NURSING:

Eligibility criteria: M.Sc Nursing

Duration of study: 1 year (full time), 2 years (part time).

Examination: University.

Registration:  Additional.

PhD IN NURSING:

Eligibility criteria: M.Sc Nursing/ M.Phil Duration of study: 3-5 years. Examination: University.

Registration: Additional

POST BASIC SPECIALTY DIPLOMA COURSES:

Eligibility criteria: R.N, R.M with one year experience.

Duration of study: 1 year.

Examination: University/ board.

Registration: Additional.

Post basic specialty courses:

❖ Post basic diploma in oncology nursing

§  Provide quality care to patients with an actual or potential diagnosis of cancer.

§   Manage & supervise patient care in clinical and community settings.

§  Teach nurses, allied health professionals, patients and communities in areas related   to oncology nursing.

§  Conduct research in areas of oncology nursing.

❖ Post basic diploma in nurse practitioner in midwifery

§  Provide quality care to mother and neonate.

§  Manage and supervise care of mother and neonate at all the three levels of care.

§  Teach nurses, allied health professionals, patients and communities in areas related to mother and neonate care.

§  Conduct research in areas of mother and neonate care.

v  Post basic diploma in neonatal nursing   

§  Provide quality care to neonates.

§  Manage & supervise care of neonates at all the three levels of care.

§  Teach nurses, allied health professionals, patients and communities in areas related to neonatal nursing.

§  Conduct research in areas of neonatal nursing.

v Post basic diploma in psychiatric/ mental health nursing

§  The students after completion of the course will be able.

§  Provide quality nursing care to individuals suffering from mental and emotional disorders.

§  Manage & supervise care of mentally ill patients in clinical and community settings

§  Teach nurses, allied health professionals, family members and communities in areas related to mother and psychiatric nursing.

§  Keep pace with the developments in other related discipline for effective management of psychiatric patients.

§  Conduct research in areas of psychiatric nursing.

v Post basic diploma in emergency and disaster nursing

§  Provide quality care in emergency & disaster situations.

§  Manage & supervise patient care in pre hospital and hospital settings.

§  Teach nurses, allied health professionals, patients and communities in areas related to emergency and disaster nursing.   

§  Conduct research in areas of emergency and disaster nursing.

v Post basic diploma in critical care nursing  

§  Provide quality care to critically ill patients.

§  Manage & supervise care of ill patients.

§  Teach nurses, allied health professionals and family members in areas related to critical care nursing.

§  Conduct research in areas of critical care nursing.

v Post basic diploma in cardio-thoracic nursing

§  Provide quality care to patients cardio-thoracic disorders.

§  Manage & supervise care-of patients with cardio-thoracic disorders.

§  Teach nurses, allied health professionals and family members in areas related to cardio-thoracic nursing.

v Post basic diploma in orthopedic & rehabilitation nursing

§  Provide quality care to patients with orthopedic & neuromuscular disorders.

§  Manage & supervise care of patients with orthopedic & neuromuscular disorders.

§  Teach nurses, allied health professionals, parents and communities in areas related to orthopedic & rehabilitation nursing.

§  Conduct research in areas of orthopedic & rehabilitation nursing.

v Post basic diploma in neuro science nursing

§  Provide quality care to neuro patients.

§  Manage & supervise care of neuro patients.

§  Teach nurses, allied health professionals and patients and communities in areas '   related; to neuro patients.

§  Conduct research in areas of neuro science nursing.

v Post basic diploma in operation room nursing

§  Provide quality care to patients in OR.

§  Manage & supervise care of patients in OR.

§  Teach nurses, allied health professionals and family members in areas related to OR nursing.

§  Conduct research in areas of OR nursing.

4.    CALL FOR CHANGE IN NURSING EDUCATION:

It is estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. More resent estimates say that these numbers may be much higher. The IOM (institute of medicine) report focused on the fragmented nature of the health-care delivery system as being the major contributor to the high and inexcusable error rate. This fragmentation leads to a lack of continuity and multiple patient handoffs.

The IOM in two follow up reports in 2001 and 2003 stressed that the health care system as currently structured does not, as a whole, make the best use of its resources and called on all health care organizations and professional groups to promote health care that is safe, effective, client centered, timely, efficient, and equitable. The IOM committee on the health professions Education Summit urged that all health professionals be educated to deliver patient centered care as members of an interdisciplinary team, emphasizing evidenced based practice, quality improvement approaches and informatics.

It is evident that the leadership in nursing is of supreme importance at this time. Nursing has faced many critical situation in its long history, but probably none more critical than the situation it is now in, and none in which the possibilities, both of serious loss and of substantial advance, are greater. What the will be depends in large measure on the kind of leadership that the nursing profession can give in planning for the future and in solving stubborn and perplexing problems. If past experience is any criterion, little constructive action will be taken without intelligent and courageous leadership.

Each of these prevailing health problems is suited to the nursing paradigm. Their amelioration is what nursing students are educated to do. The advancement of medical, science and technology has changed the landscape of health and illness. Not only are people living much longer, they are living with chronic illness.

One of natural responses to the changes in health care, new technologies, and calls for a better educated workforce has been to expand current educational requirements. Course requirements, clinical hours, and credit hours required for graduation from associate degree (ADN), baccalaureate (BSN), and master's degree in nursing (MSN) programs have grown exponentially. Despite the growth in these requirements, graduates and employees still identify additional content and experiences needed to practice in today's health care environment, including business principle of health care, evidence-based practice, and emerging areas of science such as genomics and environmental health.

The institute of Medicine, American Hospital Association, the Robert Wood Johnson Foundation, and other groups external to nursing have called on all the health professions to change the way future health professionals are educated. New ways of educating health professionals, including inter-professional education and practice, and new practice models must be developed.

5.  EXCELLENCE IN NURSING EDUCATION MODEL:

5.1. HALLMARKS OF EXCELLENCE IN NURSING EDUCATION

Students

Students are excited about learning, exhibit a spirit of inquiry and a sense of wonderment, and commit to lifelong learning

Students are committed to innovation, continuous quality/performance improvement, and excellence

Students are committed to a career in nursing.

Faculty

The faculty complement includes a cadre of individuals who have expertise as educators, clinicians, and researchers.

Faculty members are accountable for promoting excellence and providing leadership in their area(s) of expertise.

All faculties have structured preparation for the faculty role, as well as competence in their area(s) of teaching responsibility.

Continuous Quality Improvement

The program engages in a variety of activities that promote excellence, including accreditation from national nursing accreditation bodies.

The program design, implementation and evaluation are continuously reviewed and revised to achieve and maintain excellence.

Curriculum

The Curriculum is flexible and reflects current societal and health care trends and issues, research findings and innovative practices, as well as local and global perspectives.

The curriculum emphasizes students' values development, socialization to the new role, commitment to lifelong learning, and creativity.

The curriculum provides learning experiences that prepare graduates to assume roles that are essential to quality nursing practice.

The curriculum is evidence-based.

Teaching/Learning/Evaluation strategies

Teaching/Learning/Evaluation strategies are innovative and varied to facilitate and enhance learning by a diverse student population.

Teaching/Learning/Evaluation strategies used by faculty are evidence-based.

Resources

Partnerships in which the program is engaged promote excellence in nursing education, enhance the profession, benefit the community and expand service/learning opportunities.

Technology is used effectively to support teaching/learning/evaluation processes.

Financial resources of the program are used to support curriculum innovation, visionary long range planning, faculty development, an empowering learning environment, creative initiatives, continuous quality improvement of the program.

Innovation

The design and implementation of the program is innovative.

The innovativeness of the program helps to create a preferred future for nursing.

Educational Research

Faculty and students contribute to the development of the science of nursing education through the critique, utilization, dissemination or conduct of research

Environment

The educational environment empowers students and faculty and promotes collegial dialogue, innovation change, creativity, values development, and ethical behavior.

Leadership

Faculty, students, and alumni are prepared for and assume leadership roles that advance quality nursing care; promote positive change, innovation, and excellence; and enhance the power and influence of the nursing profession.

6.    A NEW MODEL FOR NURSING EDUCATION:

 

The core essentials are

1.     Scientific underpinnings for practice.

2.     Organizational and system leadership for quality improvement in systems thinking.

3.     Clinical scholarship and analytical methods for evidenced based practice

4.     Information system and technology for the improvement and transformation of patient-centered health care.

5.     Health-care policy for advocacy in health care.

6.     Interprofessional collaboration for improving patient and population health outcomes.

7.     Clinical prevention and population health for improving the nation's health.

8.     Advanced nursing practice for specialty roles

7.    ROLE  OF  THE  NURSE  EDUCATOR  IN  THE  21 CENTURY:

There are many national reports indicating the need for change in health care and in the education of health-care professionals in particular. In its report entitled crossing the Quality Chasm: A New Health System for the 21^st Century, the Institute of Medicine (IOM, 2001) acknowledges that the education of health professionals in need of major change and asserts that the clinical education of health professionals is outdated and not responsive to the present or future needs in health care. As its guiding vision, the IOM (2003) makes the recommendation that health professionals should be educated to deliver patient-centered care within an interdisciplinary team that emphasizes evidence-based practice, quality improvement approaches, and informatics. The backdrop of needed change will serve as the starting point for discussions regarding essential attributes needed in nursing education. Emphasis on student learning, promotion of evidence-based practice and development of authentic student-teaejier relationships are those attributes that are foundational to effective teaching.

7.1 EMPHASIS ON STUDENT LEARNING:

Over the past decade, education has shifted from a teacher-centered to a student centered approach. Understanding and facilitating student learning must be a priority for the nurse educator of the 21^st century.

In nurse education research, there always has been a greater focus on the outcomes of learning, rather than on understanding the processes involved in learning. Research aimed at understanding how students learn result in the development of best practices in teaching. For example, there is some empirical support for the use of concept mapping as a strategy that promotes critical thinking. In order to facilitate learning, nurse educators must be cognizant (aware) of a variety of factors that students bring to the learning setting. For example, a typical classroom may consist of second-degree students or second career students (Boomers), returning or transfer students who may be in their mid 20s and 30s (Genexers) or students who attend college immediately after graduating from high school (Millennials).

Skillful assessment of student learning outcomes is also needed in order to evaluate how students learn and the degree to which teaching strategies encourage meaningful learning. A recent survey of nursing students suggests that the content demands of the nursing curricula are so great that little time is left for students to assimilate that content into useful clinicaj knowledge. Novice nurses are less aware of their thinking and learning processes when compared with experiences nurses.

7.2. PROMOTION OF EVIDENCE-BASED PRACTICE:

The primary focus of health care institutions today is on the provision of quality care within a cost effective framework. This emphasis on outcomes has led to a national movement requiring evidence based care. A survey to determine the readiness of U.S. nurses for evidence-based practice and found that respondents reported a lack of value for research in practice.

The movement toward evidence based practice requires that educators and practitioners engage in collaborative research. The nurse educator of the future must form collaborative relationships not only with practicing nurses but also with other members of the health care team.

With patient-centered care as its focus, nursing and medicine, for example, need to collaborate in clinical studies in order to improve outcomes of care. Most importantly, nurse educators must role model this behavior for students so that students learn that practice and research coexist and cannot be seen as separate entities. Research becomes meaningfully grounded in practice rather than a theoretical topic unrelated to the practice setting.

Evidence-based practice is here to stay and discussions centering on nursing education and nursing practice must be strongly grounded in nursing research.

7.3. EMPHASIS ON AUTHENTIC STUDENT-TEACHER RELATIONSHIPS:

There is mounting evidence to suggest that a thoughtful student-teacher relationship is essential for students to develop and grow. The traditional behaviorist model viewed students as empty vesicles who were eager to receive knowledge transmitted from the teacher. The humanistic approach recognizes that students have their own experiences that enrich learning while also viewing the student as a participant in learning.

Since that time, others have carefully examined the centrality of the student-teacher connection in promoting learning. The current research suggests that learning and student development are promoted through strategies aimed at getting to know students and connecting to students through more thoughtful, concerted means.

When investigating student perceptions of effective and ineffective clinical instructors, it was found that students perceived that the most effective clinical instructors were those having strong interpersonal relationships with students. The nurse educator of the future will need to establish authentic relationships with students grounded in mutual trust and respect so that students gain the self-confidence to achieve their potential.

8.   MUSINGS: REFLECTING ON THE FUTURE OF NURSING EDUCATION:

8.1. SKILLED STUDENT-CENTERED TEACHING:

All leaders in nursing education and committed nurse educators have contributed central exemplars toward a prototype of skill in student-centered teaching in nursing education. There are three themes of skilled Student-centered teaching in nursing education.

These are:

1.     The nurse educator maintains in student-centered teaching and in self as a student-centered teacher.

2.     The nurse educator focuses on how his or her teaching practices influence students learning.

3.     The nurse educator is critically reflective about his or her teaching practices, beliefs, and assumptions.

Confidence:

The ability to teach in a student-centered way requires considerable confidence in one's professional knowledge, teaching skill, and knowledge of the learners. Several authors suggested that nurse educators develop confidence in student-centered teaching as they develop a "firm grounding in the pedagogy of the teaching/learning experience".

Without such a foundation, nurse educators have a tendency to believe in the mode of teaching rather than in their skill as student-centered teachers. Nurse educators grounded in the tenets of student-centered teaching know that the most significant thing about teaching is that students learn in the context of a learning partnership in which their voice is equal in importance to that of the teacher

Focusing on Students' Needs:

The authors present student-centered teaching as a journey of creative discovery of what teaching behaviors and responses will best meet the diverse needs and ways of various students. They highlight the need to make connections so that the learner will be able to engage and find meaning in the learning experience.

Young refers to student-centered teaching as focusing on students'needs, rather than imposing what the teacher believes is essential to learn, as "letting learn". The ideal of student-centered teaching is that rather than students expending energy determining what the teacher wants, they explore and discover what they want and need to know.

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