a ourse administering a ug onerma toa client with fecal ie, should place a client in what a? ‘on the left side with the head ff the bed elevated 45 degrees (On the right side of the body with the head of the bed elevated at 45 degree angle On left sims position Right sims position You are performing a physical tation on your patient. You have en his vital signs, height and Which phase of the nursing js do these activities describe? Assessment Planning Implementation Evaluation The nurse prepares to ter medication by the buccal Ihere should the nurse place dication? On the child's skin Between the client’s cheek and gum Under the client’s tongue Inject in the IV Y-port Answer: ¢ Rationale In administeri a ing an enema, the nurse ‘ould position the patient on his left {ide in Sims’ position with the right nee flexed. This position allows the Solution to flow downward by gravity along the curve of the sigmoid colon and rectum, thus improving the effectiveness of the enema Answer: A Rationale The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, ‘economic, and life-style factors as well. Answer: ile: Pata initain refers oa rute of administration/topical route of administration by which drugs held or ‘applied in the buccal area (in the cheek) diffuse through the oral mucosa which line the mouth) and enter directly into the bloodstream.cepts appear in each When scheduling segmental ral drainage treatments, the nurse Hd realize that the least iate time of the day to receive At bedtime After a meal Before a meal On awakening Nursing has four basic concepts, called ‘metaparadigms. We can call this Conceptual framework of nursing theories in general since a Metaparadigm consists of a group of Felated concepts. The four ‘metaparadigms of nursing are person or client, environment, health, and nursing. Answer: D Rationale: Maslow stated that people are motivated to achieve certain needs When one need is fulfilled a person seeks to fulfill the next one, and so on. This five stage model can be divided into basic (or deficiency) needs (e.g. physiological, safety, love, and esteem) and growth needs (self. actualization). Among the physiologic needs, the need for air or oxygen receives the highest priority. Answer: B Rationale: Doing postural drainage after meal may cause a little discomfort to the patient and may cause reflux of the ingested food. The procedure may be done at bedtime, upon awakening, or before a meal.drugs is less than of the drugs p causes diminished eople think of protein as body- utrient, the material of strong and rightly so. No new living be built without them. leficiency can have devastating people’s health. Marasmus inly adults are victims cause is usually an infection ere wasting of body fat and juscle occurs limbs and face swell with jema, and the belly bulges ith a fatty liver FUNDAMENTALS OF NURSING Answer: B Rationale: An antagonistic drug effect is when 2 drugs negate each other. An example would be a drug that causes high blood pressure such as a stimulant, and a drug that lowers blood pressure, such as nitroglycerin. They would be considered antagonistic with regard to blood pressure. This may be bad, since you may not get the desired effect when you take the 2 drugs together. Answer: C Rationale: Marasmus is commonly represented by a shrunken, wasted appearance, loss of muscle mass and subcutaneous fat mass. Buttocks and upper limb muscle groups are usually more affected than others. Marasmus is not always linked to severe edema. Other symptoms of marasmus include unusual body temperature (hypothermia, pyrexia), anemia, edema, dehydration (as characterized with consistent thirst and shrunken eyes), hypovolemic shock (weak radial pulse, cold extremities, decreased consciousness), tachypnea (pneumonia, heart failure), abdominal manifestations (distension, decreased or metallic bowel sounds, large or small liver, blood or mucus in the stools), ocular manifestations (corneal lesions associated with vitamin A deficiency), dermal manifestations (evidence of infection, purpura, and ear, nose, and throat symptoms (otitis, rhinitis).ed out closely for signs of? lalos around vision creased BP, increased PR pil constriction stlessness tient who is suspected to to receive which of the dissolve blood clots? client receiving digoxin must oped pulmonary embolism FUNDAMENTALS OF NURSING Answer: A Rationale Aminoglycosides can cause fetal harm when administered to a pregnant woman. Aminoglycosides cross the placenta and there have been several reports of total irreversible, bilateral congenital deafness in children whose mothers received streptomycin during pregnancy, Although serious side effects to the fetus or newborns have not been reported in the treatment of pregnant women with other aminoglycosides, the potential for harm exists. Answer: A Rationale: Common adverse effects of digoxin therapy include loss of appetite, nausea, vomiting, and diarrhea as gastrointestinal motility increases. Other common effects are blurred vision, visual disturbances (yellow- green halos and problems with color perception), confusion, drowsiness, dizziness, insomnia, nightmares, agitation, and depression, as well as a higher acute sense of sensual activities. Answer: B Rationale: Thrombolytic drugs are used in medicine to dissolve blood clots in a procedure termed thrombolysis. They limit the damage caused by the blockage or occlusion of a blood vessel. amWoolen fibers Synthetic fibers Cotton blankets Blankets made of wool “Utilize huff coughing techniques.” “Think of blowing a whistle.” “Think of blowing a candle flame so it bends without going out.” “Avoid doing normal forceful coughing.” he purpose of pursed-lip 1g to patients with chronic ive pulmonary diseases is: event bronchial collapse inimizing lung expansion laximizes air trapping rengthen intercostal muscles FUNDAMENTALS OF NURSING Answer: C Rationale: Materials that generate static electricity include wool and synthetic fibers. Cotton blankets should be used and clients and caregivers should be advised to wear cotton. Answer: 0 Rationale: Normal forceful coughing is highly effective, but some clients may lack the strength or ability to cough normally. Normal forceful coughing Involves the client inhaling deeply and then coughing twice while exhaling. Clients may practice pursed lip breathing by blowing on a candle flame so it bends without going out, or blowing a ping-pong ball across a table. A client with a pulmonary condition (e.g. COPD) is instructed to exhale through pursed lips and to exhale with a “huff’ sound in mid- exhalation. The huff cough helps prevent the high expiratory pressures that collapse diseased airways. The client is taught to purse the lips as if about to whistle and blow slowly and purposefully, tightening the abdominal muscles to assist with exhalation. Answer: A Rationale: Pursed-lip breathing helps the client develop control over breathing. The pursed-lips creates resistance to the air flowing out of the lungs, increasing the pressure within the bronchi, thereby prolonging exhalation and preventing airway collapse by maintaining positive airway pressure. 173 ULTIMATE TESTING GUIDE to Nursing Reviewthe: trimester week of pregnancy 1* month of pregnancy Which of the following should done when performing post- care? Raise the head of the bed and place a pillow under the patient’s head Don't try to remove the dentures Put a towel under the patient's chin None of the above FUNDAMENTALS OF NURSING Answer: B Rationale: Isotretinoin, a vitamin A metabolite, Is PREGNANCY CATEGORY X- meaning it is a major contraindication to pregnancy. It has caused severe fetal malformations and spontaneous abortion Answer: D Rationale: A condition called liver mortis will begin to set in approximately 20 minutes after the patient has passed. Once the circulation in the body has stopped, gravity takes over, pulling the blood downward. If the head is not elevated, the blood will begin to pool around the sides of the face, the earlobes and the neck, leaving a deep, reddish-purple discoloration in these areas. To prevent this, raise the head of the bed to a 30-degree angle and place one or two pillows under the patient’s head. The deceased person's family often wants to view the body, and because it is important that the deceased appear natural and comfortable, nurses need to place the body in an anatomic position, place dentures in the mouth, place a rolled ‘towel under the patient’s chin and close the eyes and mouth before rigor mortis sets in. Rigor mortis usually leaves the body about 96 hours after death“You should ask your doctor Fegarding this concern* "You may decide if you want it oF not” “You may do it as long as you are trained and has sufficient knowledge.” “You are not allowed to do it on your own.” Which of the following nursing ities may not be delegated to Ing aide Urine collection Vital signs monitoring Health education Post-mortem care A patient who is scheduled for ‘of diagnostic tests tomorrow put under which level of care? Level ii Level | Level i Level iv FUNDAMENTALS OF NURSING 2 Rationale: Some clients may wish to administer their own enemas. If this is appropriate, the nurse validates the client’s knowledge of correct technique and assists as needed Answer: C Rationale: The following tasks may not be delegated to UAP: assessment, interpretation of data, making a nursing diagnosis, creation of a nursing care plan, evaluation of care effectiveness, care of invasive lines, administering parenteral medications, performing venipuncture, insertion of nasogatsric tubes, client education, performing triage, giving telephone advice, performing sterile procedures. The other options may be delegated to the UAP. Answer: B Rationale: Intensive care (Level IV), patients are those who are in constant danger or serious injuries. Total care (Level til) patients are usually those who are bedridden and who lack of strength and mobility to do ADL (patients on CBR, immediate post-op, comatose). Intermediate (Level |!) requires some help from the nursing staff with special treatments or certain aspects of personal care (patients with IV fluid, NGT). Self-care (Level |) patients are capable of carrying ADL's. wnFUNDAMENTALS OF NURSING 43, The following patients may be transferred by an unlicensed assistive Personnel, except? ‘A. Mr Del Rosario, a 65-year old client Ms. Gasat, a client who has recently undergone craniotomy Mr. Maravillo, who is scheduled for an elective surgery All of the above 44. During staff shortage, the head nurse will need to delegate some tasks to unlicensed assistive personnel, Which should not be included in the guidelines? A, The patient must be in a chronic but stable condition The procedure must have a predictable result The task must be routine The task must require advanced skill or knowledge Which of the following should not be observed in normal urine? Output of 2 cups per day No blood traces ‘Transparent in appearance Straw colored Answer ® Rationale AUAP should Pe transfer safely elderly client since that are considers were additional ® e specifi jestion). Ther In the avtinat an absence fod jeve thal ead mweair the UAP'S Skills. HOW, a fresh postoperative patient is, by Jefinition, in somewhat UnStalia cenaition and the nurse MUSt BSSESS an Supervise the initial transfer. . Answer: 0 Rationale: The task to be delegated to UAP'S n not require a substantial amount: scientific knowledge or technice All other options are correct. ‘Answer: A Rationale; Output of less than 30mL/hr: indicate decreased blood kidneys and should be Feported. One cup is 250 mI. The other options characteristics of urine,of restraints from reaching their act out? my restraints restraints patient has been observed to haviors that may require the straints. The following must be when selecting restraints, ill cause little or no trictions to client’s jovements n be changed easily ill not interfere with medical FUNDAMENTALS OF NURSING Answer: B Rationale: Elbow restraints are used to prevent infants or small children from flexing their elbows to touch or scratch a skin lesion or reach the head when a scalp vein infusion is in place. A mummy restraint is a special folding of a blanket or sheet around the infant to prevent movement during a procedure such as gastric washing, eye irrigation, or collection of a blood specimen. A mitt or hand restraint is used to prevent confused clients from using their hands or fingers to scratch and injure themselves. A crib net is simple a device placed over the top of the crib to prevent active young children from climbing out if the crib. Answer: D Rationale: The five criteria when selecting restrains include: It restricts the client movement as little as possible. If a client needs to have one arm restrained, do not restrain the entire body. It does not interfere with the client’s treatment or health problem. It is readily changeable. It is safe for the particular client. It is the least obvious to others. Both clients and visitors are often embarrassed by a restraint, even though they understand why it is being used.will help under the Transmission-Based 1S as recommended by CDC? Mearing clean gloves when it is Mot expected that the patient ill splash body fluids Wearing an N95 respirator mask Washing hands after contact jth patient's body secretions eventing injuries from the sed of syringes. he nurse maintains this when performing TSB: ial distance lersonal distance timate distance lublic distance FUNDAMENTALS OF NURSING Answer: A Rationale: Broadening the stance increases stability. Leaning backwards takes the line of gravity off the base of support Tensing the abdominal muscles and bending the knees are useful when lifting heavy objects. Answer: B Rationale: Tier one is also known as the Standard precautions which are designed for all clients in the hospital. Wearing a respiratory device is included under Tier Two or transmission-based precautions (airborne). All other options are recommended isolations precautions under Tier One (Standard Precautions). Answer: C Rationale: Intimate distance communication is characterized by body contact, heightened sensations of body heat and smell, and vocalizations that are low. Examples include cuddling a baby, touching the sightless client, positioning clients, observing an incision, performing TSB, and restraining a toddler for an injection. Intimate: touching to 1 % feet. Person % to 4 feet. Soci feet. Public: 12 to 15 feet. Personal space is the distance people prefer in interactions with others.In obtaining throat culture from jpected TB client, all of the jing holds true, except? This may be done by patient on a sitting position This can only be done by medical doctors Depressing the tongue may be necessary None of the above Nurse Michael believes that the of the ordered Penicillin drug of | Rosario is unusually high. What he do? Revalidate the order with Dr. Del Rosario Ask the pharmacist regarding the drug Discontinue giving the Medication Give the ordered medication Answer: 8 Rationale: A competent nurse demonstrates organizational and planning abilities, and has 2 or 3 years of experience. An advanced beginner demonstrates marginally acceptable performance. A proficient nurse has 3 to 5 years of experience and perceives situation as @ whole rather than in terms of parts. ‘An expert nurse performance is fluid, flexible, and is highly proficient and has more than 5 yrs of experience. Answer: B Rationale: Nurses can also obtain throat specimen. The sitting position and extension of the tongue help expose the pharynx; saying “ah” relaxes the throat muscle and helps minimize contraction of the constrictor muscle of the pharynx (gag reflex). If posterior pharynx cannot be seen, depressing the tongue with a tongue blade may be necessary. Answer: A Rationale: Anytime a nurse questions an order, the nurse should call the person who wrote the order for clarification. Do not give the medication because knowing the dose is outside the normal range and not questioning the order could lead to client harm and liability for the nurse. Calling the pharmacist is not the best answer because the nurse needs to obtain clarification from the person who wrote the order and the nurse should contact the physician first before deciding to not administer the medication. The physician may have made a mistake or may provide the rationale for why the unusual dosage needs to be given.6 Bat in the maeming and asks YOU things she should expect during procedure. Which of the following should you include in your response A. “This is a very invasive procedure that requires general anesthesia.” "You must lie stil during the procedure” “You will be exposed to high doses of radiation.” “Loud noises, if heard, are 2 cause of concer” 62. _The patient presents the following: Na: 139 mEq/L, Ca: 4.9 mEq/ LK: 3.4 mEq/L. Which of the following should you advise to the patient? A. Increase intake of fruits such as bananas and papayas Discourage intake of salt-rich food Ensure to include milk and milk products on the diet D. Both A and C. 63. Before collecting samples for ABG analysis, the nurse must perform Allen’s Test. This checks patency of the: Radial artery Radial vein Ulnar artery Ulnar vein answer: 8 Rationale: ic reson: Magnetve medical test that watch slides in yer. The procedure does not ‘iaiation. Inform the patient that the will hear loud noises during procedure and is expected. Answer: A Rationale: The patient is experiencing hypokalemia or decreased serum: 6 potassium level. Therefore, the patient’s temps must be advised to increase intake ste. Which of potassium-rich foods such as a correct? cantaloupes, apples, oranges, and banana, a for bes: Answer: C Rationale: A8G specimen colle fat but it the ulnar circulati collecting the tons is sufficient ction is the 's important to ens sample to ensure th Circulation i in the ha‘experiencing acute Is expected to ch of the following ABG Which of the following ions are likely to cause decrease patient's body temperature? Increased thyroxine output Exercise Ovulation Senescence The nurse is to measure the it’s temperature via the rectal hich of the following is not 1? The nurse uses the rectal site for best accuracy The rectal site provides core temperature measurement It is contraindicated to patients with significant hemorrhoids, immunosuppression, and bleeding tendencies None of the above What may happen to the if the patient will not be id to take some rest before ring the blood pressure after i the stairs? It will cause false high results ‘twill not affect the reading ‘twill yield accurate results Wtmay cause false low readings FUNDAMENTALS OF NURSING Answer: A Rationale: Patients who are having episodes of asthma attack are releasing carbon dioxide so they develop hypocapnia and respiratory alkalosis as manifested by decreased PaCO2 and increased pH. Answer: D Rationale: The following conditions increases body ternperature: increased thyroxine levels, increased metabolism, stress, fever, ovulation, physical activities, and hypovolemia Old age (senescence) decreased patient’s temperature. Answer: Rationale: All of the following statements are correct regarding the use of rectal site when measuring patients’ body temperature. Answer: A Rational The following may cause false high reading during BP monitoring: Exercise, ingestion of food, alcoholic drinks, and beverages, too narrow bladder cuff, smoking, and making the arm unsupported upon assessment. ULTIMATE TESTING GUIDE to Nursing Reviewvisually-impaired. His you for the measures they t You will include all of except? ke sure to rearrange the iture regularly.” Place the bed in its west” position move all the clutters in the in walking, make sure to on his side.” Presented with the White blood cells: ‘of 5, 000, 000/ mm3, of 300, 000/mm3. pulse rate varies according to r of factors. All of the following hold true about pulse rate, age increases, pulse rate jecreases ult females have higher pulse than adult males ae FUNDAMENTALS OF NURSING Answer: A Rationale: For clients with visual impairments, nurses need to do the following in 2 health care setting: orient the client to the arrangement of room furnishings and maintain an uncluttered environment; keep pathways clear and do not rearrange furniture without orienting the client; organize self-care articles within the client's reach and orient the client to his or her location;; keep the call light within easy reach and place the bed in the low position; and assist with ambulation by standing at the client's side, walking about 1 foot ahead, and allowing the person to grasp your arm. Confirm whether the client prefers grasping your arm with dominant or non-dominant hand. Answer: C Rationale: The patient's WBC is very low (normal: 5, 000-10, 000 mm/3) which makes him/her prone to infection. The patient has normal platelet and RBC count. Answer: Rationale: Fever increase pulse. All other options are true about pulse rate.Santiago, 57 years old, has from emphysema for He was admitted in the to exacerbation of his Ipon assessment his chest, to find? lurse Gloria was tasked to 2 cephalocaudal physical int to her patient on the EENT jer the examination, she ted the findings accordingly. ding the chart, one entry jeber negative”. This can be ed as: probable conductive hearing roblem normal finding n apparent sensorineural hearing loss in abnormal result IMrs. Curtis, who is suspected to jeloped a sensory ataxia, had @ Romberg’s test. The positive ans that: The patient cannot maintain balance while standing with eyes closed The patient is able to maintain Upright position with eyes open Or shut The patient cannot understand the nurse’s simple instructions The patient cannot express his Wish to go to the bathroom FUNDAMENTALS OF NURSING Answer: C Rationale: The normal AP vs. Transverse chest diameter is 1:2. Patients with emphysema experience air trapping causing the characteristic barrel chest (1:1 or 2:1 ratio) Answer: B Rationale: Weber negative is a normal result. This means that the sound can be heard on both ears upon placing the tuning fork on top of the patient’s head. ‘Answer: A Rationale: Positive Romberg’s Test means that the patient was not able to maintain her balanced whole standing with eyes closed. suerasare recTiNG GUIDE to Nursing ReviewMacon was rushed into the Emergency Department who was complaining af abdominal pain. Base cn inital assessment, appendicitis suspected. The nurse expects that ihe patient willbe pointing pain on whic of the following abdominal regions A. Right iliac 8. Right lumbar . Right hypochondriac D. Right epigastric 80. The nurse is preparing a Snellen chart for the physical examination. This is used to assess which of the following cranial nerve/ s? Ron 8 WWM c ov o. LW\ 81. Mr. Arnold Caro was admitted to the hospital after falling from the stairs. Upon examination, Nurse Jessica called Mr. Caro’s name and that’s the only time he opened his eves. The patient raised his legs and hands when asked to do so. The Patient was also oriented to time, Pisce and person. Mr. Caro’s Gcs score is: A M:6,V:5, 8. M:5,V:5, £3 c M:6,V:5, Dd. M:5, Vi 4, 6:4 ‘Answer: A Rationale: The appendix can be p right iliac/inguinal region, & must always ret figs has § lobes in te ihe lungs are separate rominent fissures On the lung. How many $ eft lung have? Answer: A Rationale: Cranial Nerve Il or the Optic responsible for our sense of be assessed with the use of ¢ such as Standard Snellen ay Three Eight Ten Four Answer: A Rationale: 3 Motor response — obeys command (6), Verbal resp oriented to time place Eye opening = eyes command or speech (3).sa newly-hired pital that uses computer ting care. One disadvantage ic documentation is. Euracy of information S in patient care Nn assessing the client the always remember that the lobes in total. The lobes of ire separated by deep, fissures on the surface of jow many segments does the Torres, a client with iron lanemia was prescribed with fate tablets. Which of the jealth teachings to this client priate? the drug on an empty ach for better absorption the drug foods rich in fibers, like tables to prevent stipation a straw to prevent staining re teeth rk-colored stool is a Mless side effect of the drug FUNDAMENTALS OF NURSING Answer 6 Rationale: One disadvantage of electronic tion downs in Advantages include legible accuracy, and mini ent care, Answer: B Rationale: The left lung has 2 lobes and 8 segments while the right lung h ‘Answer: C Rationale: Taking Iron preparation/syrup, and not TABLETS, may cause staining of the teeth. To prevent this, the use of straw may be advised to the patient. All other options are appropriate.Houten, assigned nurse for Is trying to contact his Physician to report a his client's. status however, {Is unable to take the call galled Nurse Van Houten minutes and relayed the Insist that he talk to the hysician instead lote the verbal order and let fe physician sign within 24 hrs ranscribe the phone order and ‘ument appropriately lurse Fantine is about to ir a tablet to her client, Mr. hen the client says, “This 0k like the drug | usually ich of the following is the best by Nurse Fantine? is is it Mr. Valjean. You must seen wrong.” laybe your doctor ordered a ferent medication.” I recheck your medication ers. it me leave the tablet here le | check with your doctor, Valjean.” FUNDAMENTALS OF NURSING Answer: B Rationale. The order must come from the physician himself Guidelines for Telephone and Verbal Orders: Write the complete order and read it back to the physician Question for any ambiguous or unusual orders Indicate whether telephone or verbal order in the physician’s order sheet Order countersigned by the physician within 24 hours Answer: C Rationale If there is any doubt about the medication administered, the medication administration process ‘must be interrupted until the question is clarified. Medication should never be left unattended. Listen to the client. Find out any other information the client may have about a certain medication, Review the chart to make sure there is no discrepancy between the physician's order and the medication administration record. When administration medications the nurse observes specified rights to ensure accurate administration. When preparing medications, the nurse checks the medication container label against the medication admi record for three times.Be tc ratte hosp hat kn Sons from We rom ect SET vsctans onder notes. She cheat, and nurse's notes atenciton aorroned throughout the chart and (t's bn aatRcukt to monitor client’s qragress. Based on her observations, me hospital is most likely using which hat information are documentation system? Focus Charting Problem-Oniented Medical Second Source-Oriented Medical Second Rational 4 The traditional client record Is» oriented record. Each person of department makes notations in, separate section of the client's For example, the admissions department has admission st physician has physictan’s order and progress notes, nurses use. nurse’s notes, etc. In this type of record, information about a p problem is distributed thro record, SOMR are convenient because providers from each discipline easily locate the forms on which | record date and it is easy tot information specific to the The disadvantage Is that info about a particular client problem: scattered throughout the chart, difficult to find chronological information on a client’s pro progress. This can lead to communication among the team, an incomplete picture client’s care, and a lack of of care. Option A- The PIE docu model groups information i categories. It is an acronym Problems, Interventions, Evaluation of nursing care. Consists of a client care as flow sheet and progress Option B- Focus charting is make the client and client strength the focus of care, for recordi time, focus eae ually to the pri than the Plans for guurce of the each active or are drawn Notes are rec te SHOE phy] 18 win 3 ean Nurse tablets ¢ tablets 12 tablets me engaging it a program. According level Wellness Gri identify Selena’s sit Poor health environme: favorable Emergent favorable @The physician ordered in 13 & PO, BID. Ampiciliin is lable 2s 2,000 mg tablets. How many ts will Nurse Marcus administer day? 6% tablets 6 tablets 2 tablets tablets Selena is a medical unit staff Je. She is aware on the importance perce in maintaining good health, wer, due to her schedule and nsillities at work and at home as le parent, she is having a hard engaging in any form of exercise According to Dunn's High ss Grid, you properly a's situation as health in an unfavorable environment Protected poor health in a favorable environment mergent High ~ level wellness in an unfavorable environment High level wellness in a favorable environment FUNDAMENTALS OF NURSING Answer: D Rationale: Convert 2,000 mg to g: 2,000mg / 1,000 =28 Formula: Desired / Hand x vol or tab > 13g /2gx1 tab=65 or 6 % tablets Tablets / day: order: BID > 6.5 tabs x 2 = 13 tablets per day Answer: € Rationale: High-level weliness in a favorable environment. An example is a person who implements healthy lifestyle behaviors and has the biopsychosocial, spiritual, and economic resources to support this lifestyle. Emergent high-level wellness in an unfavorable environment. An ‘example is a woman who has the knowledge to implement healthy lifestyle practices but does not implement adequate self-care practices because of family responsibilities, job demands, or other factors. Protected poor health in a favorable environment. An example is an ill person (e.g,, one with multiple fractures or severe hypertension) whose needs are met by the health care system and who has access to appropriate medications, diet, and health care ; Poor health in an unfavorable environment. An example is @ young child who is starving in a drought- stricken country.Of her client. To client, she should Of the following and tongue depressor Nd Aromatic I. Sercheef, 63 years old, in the private ward for in after complaints of severe . When doing an initial r the best way for you to le client’s priority problem is erse with the relatives to ther data about history of jess auscultation to check for t congestion view the client for chief plaints and other symptoms @ physical examination while ing the relevant questions FUNDAMENTALS OF NURSING Answer: C Rationale: Several items that are frequently used in the physical examination include: Aromatic substances (e.g. Vanilla) to test the 1" cranial (olfactory) nerve Cotton balls to assess sensory Fesponse to light touch Toothpick to assess sensory response to slight pain Drapes to cover the client Gloves to reduce the transmission of microorganisms Calibrated tape measure for assessing circumference, length and width ‘Tongue depressor to inspect mouth and to stimulate gag reflex for assessing 9 and 10” (glossopharyngeal and vagus) cranial nerves Answer: D Rationale: Health history ascertains the client’s chief complaints and directs the focus of physical examination. The complete assessment data are used to: Ascertain the client’s level of health and physiological function Identify factors placing the clients at risk and to determine area of preventive nursing Confirm alterations, disease, or inability to perform the activities of daily living Identify the need for additional testing or examination Evaluate the outcomes of treatments and therapy OPTION A: Secondary data OPTION B: Chest pain suggests heart problem; auscultation for chest congestion focuses on respiratory conditions OPTION C: Interviewing the client is avoided due to the client’s chest pain aAnswer: B TALS OF NURSING urse Ryza reads three ters of Lactated Ringers pital eaten mute factor is 15. are a ning or 9 hours Answer: 67 drops The and at 800 mL level upon checking. How many drops per minute are needed so that the IV finishes in the required time? rops per minute = oe n volume X drop Total time of infusion in mit 8 receive! . eee 800 ml X 15 drops/ml faa 8. 67 gtts/ min i C63 4tts/ min ¢ callthe D. 61 gtts/min validate medical ee Retake 98. Nurse El = 67 drops / min year-old alcohol diagnosed with dient manifests jaundice and pit her assessment, the pitting edem nurse is corr ©"esponding s¢ mm in Measure [time remaining = 3 hours = minutes] [volume remai 96. A student in a cardiac unit is Answer: C performing auscultation of a client’s heart. Nurse Lucy Weg recognizes that Rationale: the student is performing pulmonic The pulmonic area is auscultation correctly when the second intercostal stethoscope is placed: sternum. + OPTION B is the co . & A. Between the apex and the tricuspid area. _ 3% sternum OPTIONS A and D: At the fifth intercostal space at locations for heart the left ‘midclavicular line C At the second intercostal i Space, left of the ‘sternumreviewing a chart of an the nurse notes that the temperature for the shift was 40 C. There is no intervention. The nurse yeck the doctor's order for an lantipyretic. ‘Ask the client whether she has received any medication for her fever Call the nurse at home to validate whether the medication was given. Retake the temperature. Nurse Elsa Katie is caring to a 65 Id alcoholic client who was sed with liver cirrhosis. The manifests severe weakness, e and pitting edema. As part of sessment, the nurse measured ting edema of her client as Smm. se is correct that the jponding scale when edema is in measurement is: u Pos u o Mang Eadji, a 78 year old was admitted due to lension. During assessment, You that he has difficulty ishing colors. Which color is misinterpreted by elderly clients? Orange Violet Red White Answer: 0 Rationale: OPTION D: The nurse should retake the client’s temperature to determine accuracy because no intervention was done. OPTIONS A, B, and C depend on the client’s present temperature reading before they are implemented, Answer: C Rationale: Scale for Describing Edema 1+ Barely detectable 2+ Indentation of 2-4 mm 3+ Indentation of 5-7 mm 4+ Indentation of more than 7 mm Answer: B Rational OPTION B: Elderly clients often expresses loss of color vision as they age. The colors are blue, violet, green. OPTIONS A, C and D: these colors are more easily distinguished.es Answer: A roamentas oF HORSE raoamermae wooing the fa client who Is ood pressure 0 ° blood retain abo Bresso ng. she should use a cuff thal “Wn Rationale: The nurse should use a blood Cuff that is 223 the diameter of the nt client’s upper arm. # ‘A. 228 the diameter ofthe cients Tow g and C- if the bladder cuff ie aan er of the client's too narrow, it will cause a false high 8, the diamete asa upper arm eter of the client's OPTION O- if a bladder cuff Is too ry ieee ae it will cause a false low reading. upper arm : e diameter of the client’s ‘ f a a : if the cuff is too narrow, the blood pressure reading will be e elevated; if it is too wide, the will be erroneously low. The width should be 40% of the circumference, 20% wider than the diameter of the midpoint, of the limb on which it is used, The arm circumference, not the age of the client, should always be use to determine cuff size. The nurse can determine whether the width of a blood pressure cuff is appro the cuff lengthwise at the the upper arm, and hold the side of the cuff edge laterally. arm. With the other hand, width of the cuff around the ensure that the width is circumference. The length also affects the accuracy of Measurement, The cuff sufficiently long to cover thirds of the limb’s cit