Foundation of PROFESSIONAL Nursing Practice 1

Review Materials

DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided.
NURSING PRACTICE I Foundation of PROFESSIONAL Nursing Practice SITUATIONAL Situation 1 Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg subcutaneously. 1. The indication for epinephrine injection for Mrs. Simon is to: A. Reduce anaphylaxis B. Relieve hypersensitivity to allergen C. Relieve respiratory distress due to bronchial spasm D. Restore clients cardiac rhythm 2. When preparing the epinephrine injection from an ampule, the nurse initially: A. Taps the ampule at the top to allow fluid to flow to the base of the ampule B. Checks expiration date of the medication ampule C. Removes needle cap of syringe and pulls plunger to expel air D. Breaks the neck of the ampule with a gauze wrapped around it 3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to: A. Inject needle at a 15 degree angle over the stretched skin of the client B. Pinch skin at the injection site and use airlock technique C. Pull skin of patient down to administer the drug in a Z track D. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle 4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: A. Syringe 3-5 ml and needle gauge 21 to 23 B. Tuberculin syringe 1 ml with needle gauge 26 or 27 C. Syringe 2 ml and needle gauge 22 D. Syringe 1-3 ml and needle gauge 25 to 27 5. The rationale for giving medications through the subcutaneous route is: A. There are many alternative sites for subcutaneous injection B. Absorption time of the medicine is slower C. There are less pain receptors in this area D. The medication can be injected while the client is in any position Situation 2 The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials. 6. Martha wants to do a study on this topic: Effects of massage and meditation on stress and pain. The type of research that best suits this topic is: A. Applied research B. Qualitative research C. Basic research D. Quantitative research

7. The type of research design that does not manipulate independent variable is: A. Experimental design B. Quasi-experimental design C. Non-experimental design D. Quantitative design 8. This research topic has the potential to contribute to nursing because it seeks to A. include new modalities of care B. resolve a clinical problem C. clarify an ambiguous modality of care D. enhance client care 9. Martha does review of related literature for the purpose of A. determine statistical treatment of data research B. gathering data about what is already known or unknown about the problem C. to identify if problem can be replicated D. answering the research question 10. Clients rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT: A. right of self-determination B. right to compensation C. right of privacy D. right not to be harmed Situation 3 Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Marios nursing care plan is to loosen and remove excessive secretions in the airway. 11. Mario listens to Richards bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be: A. Client lying on his back then flat on his abdomen on Trendelenburg position B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen C. Client lying flat on his back and then flat on his abdomen D. Client lying on his right then left side on Trendelenburg position 12. When documenting outcome of Richards treatment Mario should include the following in his recording EXCEPT: A. Color, amount and consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of client before and after the procedure D. Significant changes in vital signs 13. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT: A. Amount of food and fluid taken during the last meal before treatment B. Respiratory rate, breath sounds and location of congestion C. Teaching the clients relatives to perform the procedure D. Doctors order regarding position restrictions and clients tolerance for lying flat 14. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?

A. Respiratory rate of 16 to 20 per minute B. Client can tolerate sitting and lying positions C. Client has no signs of infection D. Time of last food and fluid intake of the client 15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is: A. Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle C. In both percussion and vibration the hands are on top of each other and hand action is in tune with clients breath rhythm D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air Situation 4 A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severe chest pain. You are assigned to take care of the client. 16. When doing an initial assessment, the best way for you to identify the clients priority problem is to: A. Interview the client for chief complaints and other symptoms B. Talk to the relatives to gather data about history of illness C. Do auscultation to check for chest congestion D. Do a physical examination while asking the client relevant questions 17. Upon establishing Mr. Regalados nursing needs, the next nursing approach would be to: A. Introduce the client to the ward staff to put the client and family at ease B. Give client and relatives a brief tour of the physical set up the unit C. Take his vital signs for a baseline assessment D. Establish priority needs and implement appropriate interventions 18. Mr. Regalado says he has trouble going to sleep. In order to plan your n ursing intervention you will: A. Observe his sleeping patterns in the next few days B. Ask him what he means by this statement C. Check his physical environment to decrease noise level D. Take his blood pressure before sleeping and upon waking up 19. Mr. Regalados lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr. Regalado, which of the following interventions would be the most appropriate immediate nursing approach? A. Moisturize lower extremities to prevent skin irritation B. Measure fluid intake and output to decrease edema C. Elevate lower extremities for postural drainage D. Provide the client a list of food low in sodium 20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: A. Making a final physical assessment before client leaves the hospital B. Giving instructions about his medication regimen C. Walking the client to the hospital exit to ensure his safety D. Proper recording of pertinent data Situation 5 Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told that she has breast cysts and that she may need surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating and feelings of tension.

21. Considering her level of anxiety, the nurse can best assist Nancy by: A. Giving her activities to divert her attention B. Giving detailed explanations about the treatments she will undergo C. Preparing her and her family in case surgery is not successful D. Giving her clear but brief information at the level of her understanding 22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. The nurse understands that Nancy is grieving for her self and is in the stage of: A. bargaining B. denial C. anger D. acceptance 23. The nurse visits Nancy and prods her to eat her food. Nancy replies whats the use? My time is running out. The nurses best response would be: A. The doctor ordered full diet for you so that you will be strong for surgery B. I understand how you feel but you have to try for your childrens sake C. Have you told your doctor how you feel? Are you changing your mind about your surgery? D. You sound like you are giving up. 24. The nurse feels sad about Nancys illness and tells her head nurse during the end of shift endorsement that its unfair for Nancy to have cancer when she is still so young and with two kids. The best response of the head nurse would be: A. Advise the nurse to be strong and learn to control her feelings B. Assign the nurse to another client to avoid sympathy for the client C. Reassure the nurse that the client has hope if she goes through all treatments prescribed for her D. Ask the other nurses what they feel about the patient to find out if they share the same feelings 25. Realizing that she feels angry about Nancys condition, the nurse learns that being selfaware is a conscious process that she should do in any situation like this because: A. This is a necessary part of the nurse client relationship process B. The nurse is a role model for the client and should be strong C. How the nurse thinks and feels affect her actions towards her client and her work D. The nurse has to be therapeutic at all times and should not be affected