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Foundation of Nursing -Comprehensive Test Part 1 1.

Using the principles of standardprecautions, the nurse would wear glovesin what nursing interventions? a.Providing a back massageb . F e e d i n g a c l i e n t c . P r o v i d i n g h a i r c a r e d.Providing oral hygiene 2. The nurse is preparing to take vital sign inan alert client admitted to the hospitalwith dehydration secondary to vomitingand diarrhea. What is the best methodused to assess the clients temperature? a . O r a l b . A x i l l a r y c . R a d i a l d.Heat sensitive tape 3. A nurse obtained a clients pulse andfound the rate to be above normal. Thenurse document this findings as: a . T a c h y p n e a b . H y p e r p y r e x i a c . A r r y t h m i a d.Tachycardia 4. Which of the following actions should thenurse take to use a wide base supportwhen assisting a client to get up in achair? a.Bend at the waist and place arms under the clients arms and liftb.Face the client, bend knees and place hands on clients forearm and liftc . S p r e a d h i s o r h e r f e e t a p a r t d . T i gh t e n his or her pelvic muscles 5. A client had oral surgery following a motorvehicle accident . The nurse assessing theclient finds the skin flushed and warm.Which of the following would be the bestmethod to take the clients bodytemperature? a . O r a l b . A x i l l a r y c.Arterial lined . R e c t a l 6.A client who is unconscious needs frequent mouth care. When performing a mouth care, thebest position of a client is: a.Fowlers positionb . S i d e l y i n g c . S u p i n e d . T r e n d e l e n b u r g 7. A client is hospitalized for the first time , which of the following actions ensure the safety of theclient? a.Keep unnecessary furniture out of the wayb . K e e p t h e l i gh t s o n a t a l l timec.Keep side rails up at all timed.Keep all equipment out of view 8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. Thenursetakes the clients vital sign hereafter. Whatphrase of nursing process is being implementedhere by the nurse? a . A s s e s s m e n t b . D i a g n o s i s c . P l a n n i n g d.Implementation 9.It is best describe as a systematic, rational method of planning and providing nursing carefor individual, families, group and community a. Ass essm e nt b.Nursing Processc . D i a g n o s i s d.Implementation 10.Exchange of gases takes place in which of thefollowing organ?

a . K i d n e y b . L u n g s c . L i v e r d . H e a r t 11.The Chamber of the heart that receivesoxygenated blood from the lungs is the? a. Le f t at rium b. Right at rium c. Le f t ve ntr icl e d.Right ventricle 12. A muscular enlarge pouch or sac that liesslightly to the left which is usedfor temporary storage of food a. Gal l bl add e r b.Urinary bladderc . S t o m a c h d . L u n g s 13.The ability of the body to defend itself against scientific invading agent such asbaceria, toxin, viruses and foreign body a.Horm ones b.Secretionc. Im muni t yd . G l a n d s 14.Hormones secreted by Islets of Langerhans a.P ro gest e ron e b.Testosteronec . I n s u l i n d.H e mo glo bin 15.It is a transparent membrane that focusesthe light that enters the eyes to theretina. a . L e n s b . S c l e r a c . C o r n e a d . P u p i l s 16.Which of the following is included inOrems theory? a.Maintenance of a sufficient intake of air b . S e l f p e r c e p t i o n c . L o v e a n d b e l o n g i n g d.Physiologic needs 17.Which of the following cluster of databelong to Maslows hierarchy of needs a.Love and belongingb.Physiolo gic needsc.Self actualization d . A l l of the above 18.This is characterized by severe symptomsrelatively of short duration. a. Chronic Illnessb . A c u t e I l l n e s s c . P a i n d . S y n d r o m e 19.Which of the following is the nurses role in thehealth promotion a . H e a l t h r i s k a p p r a i s a l b.Teach client to be effective health consumerc . W o r k s i t e w e l l n e s s d . N o n e o f t h e a b o v e 20.It is describe as a collection of people who sharesome attributes of their lives. a . F a m i l y b . I l l n e s s c.Communityd . N u r s i n g 21.Five teaspoon is equivalent to how manymilliliters (ml)? a . 3 0 m l b . 2 5 m l c . 1 2 m l d . 2 2 m l 22.1800 ml is equal to how many liters? a . 1 . 8 b . 1 8 0 0 0 c . 1 8 0 d . 2 8 0 0 23.Which of the following is the abbreviation of drops? a . G t t . b . G t t s . c . D p . d . D r . 24.The abbreviation for micro drop is a . g t t b . g t t c . m d r d . m g t s 25.Which of the following is the meaning of PRN? a.When adviceb.Immediatelyc.When necessaryd . N o w 26.Which of the following is the appropriatemeaning of CBR? a.Cardiac Board Roomb.Complete Bathroom c . C o m p l e t e B e d R e s t d.Complete Board Room

27.1 tsp is equals to how many drops? a . 1 5 b . 6 0 c . 1 0 d . 3 0 28.20 cc is equal to how many ml? a.2b . 2 0 c . 2 0 0 0 d . 2 0 0 0 0 29.1 cup is equals to how many ounces? a.8b . 8 0 c . 8 0 0 d . 8 0 0 0 30. The nurse must verify the clients identitybefore administration of medication.Which of the following is the safest way toidentify the client? a . A s k t h e c l i e n t h i s n a m e b.Check the clients identification bandc.State the clients name aloud and have the client repeat itd . C h e c k t h e r o o m n u m b e r 31. The nurse prepares to administer buccalmedication. The medicine should beplaced a . O n t h e c l i e n t s s k i n b.Between the clients cheeks and gums c . U n d e r t h e clients tongued.On the clients conjuctiva 32. The nurse administers cleansing enema. Thecommon position for this procedure is a . S i m s l e f t l a t e r a l b.Dorsal Recumbentc . S u p i n e d . P r o n e 33. A client complains of difficulty of swallowing,when the nurse try to administer capsulemedication. Which of the following measures thenurse should do? a.Dissolve the capsule in a glass of waterb.Break the capsule and give the content with anapplesaucec.Check the availability of a liquid preparationd.Crash the capsule and place it under the tongue 34.Which of the following is the appropriate route of administration for insulin? a.Intramuscularb . In t r a d e r m a l c . S u b c u t a n e o u s d . In t r a v e n o u s 35. The nurse is ordered to administer ampicillincapsule TIP p.o. The nurse shoud give themedication a . T h r e e t i m e s a d a y o r a l l y b.Three times a day after meals c . T w o t i m e a d a y b y m o u t h d.Two times a day before meals 36.Back Care is best describe as: a.Caring for the back by means of massageb . W a s h i n g o f t h e b a c k c . A p p l i c a t i o n o f c o l d c o m p r e s s a t t h e b a c k d.Application of hot compress at the back 37.It refers to the preparation of the bed with a newset of linens a . B e d b a t h b.Bed makingc.Bed shampood.Bed lining osto p r o m o t e h a n d c i r c u l a t i o n o prevent the transfer of microorganism o avoid touching the client with a dirtyo p r o v i d e c o m f o r t to prevento i d f u n n i n g s o i l e d linensrip all linens at the same time ished both sides at the time b r a c e s o i l e d l i n e n e of cleansingo cleanse, refresh and give comfort to theo expose the necessary parts of the bodyo d e v e l o p s k i l l s i n b e d b a t h o check the body temperature of the clientnique involves. I n s p e c t i o n . P a l p a t i o n . P e r c u s s i o n s c u l t a t i o n ed examining the. P a l p a t i o n s c u l t a t i o n . P e r c u s s i o n n s p e c t i o n physical examination that. P a l p a t i o n s c u l t a t i o n . I n s p e c t i o n e r c u s s i o n d for auscultation

is:e r c u s s i o n - h a m m e r . A u d i o m e t e r t e t h o s c o p e h y g m o m a n o m e t e r is best describe as:u n d s c r e a t e d b y a i r f i l l e d l u n gs o r t , h i g h p i t c h a n d t h u d d i n g d e r a t e l y l o u d w i t h m u s i c a l q u a l i t y . D r u m - l i k e ing the rectum is:. P r o n e . S i m s . K n e e - c h e s t . L i t h o t o m y the manner of walking. G a i t a n g e o f m o t i o n e x i o n a n d extension. H o p p i n g . O p t i c . O l f a c t o r y . O c u l o m o t o r . T r o c l e a r hest position is:. G e n u - d o r s a l n u p e c t o r a l . L i t h o t o m y . S i m s e a s m a l l g a u g e n e e d l e ply ice on t h e i n j e c t i o n s i t e m i n i s t e r a t a 4 5 a n g l e t h e Z - t r a c k t e c h n i q u e ost appropriate nursing order for a patient inister oxygen by Venturi mask at 24%, as a 1 hour rest period between activitiesd 1 1 . a 2 1 . b 3 1 . b 4 1 . a b 1 2 . c 2 2 . a 3 2 . a 42.dd 13.c 23.b 33.c 43.bb 14.c 24. a 34. c 44. c b 15.c 25.c 35.a 45.ab 16.a 26.c 36.a 46.vcc 17.d 27.b 37.b 47.aa 18.b 2 8 .b 3 8. b 48 .a b 1 9 .b 2 9. a 39 . a 49 . b .b 20.c 30.a 40.a 5 0 . d . T a c h y p n e a . E u p n c a . O r t h o p n e a p e r v e n t i l a t i o n iting the o r d e r f o r t h i s t e s t l o f t h e a b o v e m and Swiss cheese sandwich on wholehed potatoes and broiled chickens s e d s a l a d w i t h o i l a n d v i n e g a r a n d i c k e n b o u i l l o n physician orders a maintenance dose. Nursingv i e w i n g d a i l y a c t i v a t e d p a r t i a l orting an APTT above 45 seconds to thel o f t h e a b o v e f o u r m a i n c o n c e p t s c o m m o n t o son, nursing, environment, medicineson, health, nursing, support systemsson, health, psychology, nursingson, environment, health, nursing lows hierarchy of physiologic needs, the. L o v e . E l i m i n a t i o n . N u t r i t i o n . O x y g e n ourage them from making a decision until theirn to their concerns and answer their questions urage them to sign the consent form rightell them the body will not be available for a wakew head nurse on a unit is distressed about m p l a i n t o h e r f e l l o w n u r s e s ait until she knows more about the unitc u s s t h e p r o b l e m w i t h h e r s u p e r v i s o r rm the staff that they must volunteer to rotatetinuity of patient care promotes efficient, cost ountability is clearest when one nurse isolistic approach provides for a therapeutiction to a patient whos a u l t a n d b a t t e r y . N e g l i g e n c e a l p r a c t i c e n e o f t h e a b o v e . S l a n d e r . L i b e l . A s s a u l t spondent s u p e r i o r . D e f a m a t i o n . A s s a u l t . B a t t e r y a l p r a c t i c e ample of eased blood pressure and heart rate ands. Q u i e t c r y i n g obility, diaphoresis, and avoidance of deepa n g i n g p o s i t i o n e v e r y 2 h o u r s m p l e t e b l o o d c o u n t . G u a i a c t e s t . V i t a l s i g n s d o m i n a l g i r t h uence for assessing the abdomenympanic percussion, measurement of abdominal essment for distention, tenderness, andcussions, palpation, and auscultation cultation, percussion, and palpationead over the right lowerg n o f i n c r e a s e d b o w e l m o t i l i t y g n o f d e c r e a s e d b o w e l m o t i l i t y r m a l b o w e l s o u n d s g n o f a b d o m i n a l c r a m p i n g undergo abdominal inspection. P r o n e r e n d e l e n b u r g . S u p i n e i d e l y i n g . G e n u p e c t e r o l . S i m s rizontal recumbentl o f t h e a b o v e . S i t t i n g . S t a n d i n g e n u p e c t o r a l r e n d e l e n b u r g ure is 150/96, his. 5 4 . 9 6 . 1 5 0 . 2 4 6 or 10. I n f e c t i o n . H y p o t h e r m i a . A n x i e t y e h y d r a t i o n ameters should. R a t e . R h y t h m . S y m m e t r y l o f t h e a b o v e ld patients vital signs at 8s p i r a t o r y r a t e o n l y e m p e r a t u r e o n l y l s e r a t e a n d

t e m p e r a t u r e emperature and respiratory ratee tachycardia. F e v e r . E x e r c i s e pathetic nervous system stimulationrasympathetic nervous system stimulation is the corrects e l i n e v i t a l s i g n s s t o l i c b l o o d p r e s s u r e e s p i r a t o r y r a t e p i c a l p u l s e h pulse may not be a. A p i c a l . R a d i a l . P e d a l . F e m o r a l eatest risklert, chronic arthritic patient treated with-year old incontinent patient with gastric pathetic 63-year old COPD patient receivingurage the patient to increase her fluid intake to e a humidifier in the patients room. tinue administering oxygen by high humidityform chest physiotheraphy on a regular schedulecy seen in alcoholics. T h i a m i n e . R i b o f l a v i n . P y r i d o x i n e a n t o t h e n i c a c i d ollowing statement ispatient will find pureed or soft foods, lers or semi Fowlers position reducesion during swallowingpatient should always feed himself nurse should perform oral hygieneo assess the kidney function of a patients s t h a n 3 0 m l / h o u r m l i n 2 h o u r s m l i n 3 h o u r s 5 m l i n 4 h o u r s rease the amount of einecontaining drinks, such as coffee. B e e t s i n a r y a n a l g e s i c s o l i n w i t h p e c t i n ( K a o p e c t a t e ) 2 days. Which of theurage the patient to walk in the hallourage the patient from walking in thec o m p a n y t h e p a t i e n t f o r h i s w a l k . suit a physical therapist before allowingerbation of chronicfective airway clearance related to thick,fective airway clearance related to dry, hacking fective individual coping to COPD.in related to immobilization of affected leg. nurse discusses hairnt worry. Its only temporary y are you crying? I didnt get to the bad news o ur h a i r i s r e a l l y p r e t t y ow this will be difficult for you, but your hair ed during all of . I n f a n c y o u n g a d u l t h o o d . C h i l d h o o d . P r e g n a n c y xygen s needed for aulatory overload due to hypervolemias p i r a t o r y e x c i t e m e n t ibition of the respiratory hypoxic stimulus. Gray develops. L e t h a r g y eased pulse rate and blood pressures c l e w e a k n e s s s c l e i r r i t a b i l i t y sing interventionses the patients ability to ambulate and transferonstrate the signal system to thek to see that the patient is wearing hisl o f t h e a b o v e wn that about 40% of e r a i l s a r e i n e f f e c t i v e rails are a deterrent that prevent arails are a reminder to a patient not tosuffering frommiconscious or over fatigued patient o r i e n t e d o r c o n f u s e d p a t i e n t t i e n t w h o c a n n o t c a r e f o r h i m s e l f a t tient demonstrating symptoms of drugsry among elderlyeroscleotic changes in the blood vessels eased incidence of gallbladder diseasen a r y T r a c t In f e c t i o n i p f r a c t u r e chogenic disorder. D e p r e s s i o n p disturbances (such as bizarre dreams)a b i l i t y t o c o n c e n t r a t e c r e a s e d a p p e t i t e ascular systemeased peripheral resistance of the bloodc r e a s e d b l o o d f l o w eased work load of the left ventriclel o f t h e a b o v e ost common causea r k i n s o n s d i s e a s e l t i p l e s c l e r o s i s otrophic lateral sclerosis (Lou Gerhigs disease)z h e i m e r s d i s e a s e s most important legal responsibilitya i n i n g a c o n s e n t o f a n a u t o p s y fying the coroner or medical examinere l i n g t h e c o r p s e a p p r o p r i a t e l y ring that the attending physician issues thecurs, the nurse isiding a complete bath and dressing change ing one pillow under the bodys head andoving the bodys clothing and wrapping the o w i n g t h e b o d y t o r e l a x n o r m a l l y t e c t t h e p a t i e n t f r o m i n j u r ys e r t a n a i r w a y v a t e t h e h e a d o f t h e b e d h d r a w a l l p a i n m e d i c a t i o n s . In this case,.. Iticrendelenburg position, the head of . Absence of the apical, radial,s or semi-Fowlers position, and oralaiting to., hacking, hacking cough is. Pain related tobut doesnt recognize the.., hypokinesis, dysphagia, andelement in the

circular chain of infection. H o s t . R e s e r v o i r d e o f t r a n s m i s s i o n o r t a l o f e n t r y of the following will probably result in a ing the patients window to the outside urning on the patients room ventilatoring the door of the patients room leading intoc h o f t h e f o l l o w i n g p a t i e n t s i s a t a t i e n t w i t h l e u k o p e n i a i e n t r e c e i v i n g b r o a d - s p e c t r u m ostoperative patient who has undergonel y d i a gn o s e d d i a b e t i c p a t i e n t hand washingp or detergent to promote emulsificationw a t e r t o d e s t r o y b a c t e r i a isinfectant to increase surface tension l o f t h e a b o v e handwashing. 3 0 s e c o n d s . 1 m i n u t e . 2 m i n u t e . 3 m i n u t e s of the following procedures alwaysaginal instillation of conjugated estrogenUrinary catheterizationNasogastric tube insertionColostomy irrigationr i l e t e c h n i q u e i s u s e d w h e n e v e r : r i c t i s o l a t i o n i s r e q u i r e d erminal disinfection is performedv a s i v e p r o c e d u r e s a r e p e r f o r m e d t e c t i v e i s o l a t i o n i s n e c e s s a r y of the following constitutes a breakg sterile forceps, rather than sterileouching the outside wrapper of sterilizedural body defense that plays an active role. Y a w n i n g . B o d y h a i r . H i c c u p p i n g p i d e y e m o v e m e n t s donning sterile glovesirst glove should be picked up by grasping theecond glove should be picked up by insertingloves should be adjusted by sliding the gloved inside of the glove is considered sterile n, the nurseaist tie and neck tie at the back of the gowna i s t t i e i n f r o n t o f t h e go w n f f s o f t h e g o w n s i d e o f t h e g o w n sing interventions isall used needles before removing them fromard all used uncapped needles and syringes in ear gloves when administering IM injectionsl l o w e n t e r i c p r e c a u t i o n s s are recommendedsaging the reddened are with lotionn g a w a t e r o r a i r m a t t r e s s ring to a schedule for positioning and turningv i d i n g m e t i c u l o u s s k i n c a r e ts should bet h r o m b i n a n d c o a gu l a t i o n t i m e o d t yp i n g a n d c r o s s - m a t c h i n g e e d i n g a n d c l o t t i n g t i m e plete blood count (CBC) and electrolytee of a platelet count ist e n t i a l f o r c l o t f o r m a t i o n o t e n t i a l f o r b l e e d i n g ence of an antigen-antibody responses e n c e o f c a r d i a c e n z ym e s ite blood cell. 4 , 5 0 0 / m m . 7 , 0 0 0 / m m . 1 0 , 0 0 0 / m m , 0 0 0 / m m furosemide. H y p o k a l e m i a p e r k a l e m i a . A n o r e x i a . D y s p h a g i a ollowing statements aboutcontradictions exist for this testre the procedure, the patient shouldi gn e d c o n s e n t i s n o t r e q u i r e d ng, drinking, and medications arethe nurser l y i n t h e m o r n i n g r the patient eats a light breakfastt e r a e r o s o l t h e r a p y e r c h e s t p h ys i o t h e r a p y ies is to receivehold the moderation and notify the physician inister the medication and notify the physicianinister the medication with an antihistamine p l y c o r n s t a r c h s o a k s t o t h e r a s h ing interventions areack method of drugare the injection site with alcohol a n e e d l e t h a t s a l e a s t 1 l o n g p i r a t e f o r b l o o d b e f o r e i n j e c t i o n he site vigorously after the injection to od for determining the vastuste the upper aspect of the upper outer quadrant lpate the lower edge of the acromion process andlpate a 1 circular area anterior to the umbilicus de the area between the greater femoralite is seldom used foraccommodate only 1 ml or less of medication u i s e s t o o e a s i l y be used only when the patient is lying down not readily parenteral medicationr insulin injection. 1 8 G , 1 l o n g . 2 2 G , 1 l o n g G , 1 l o n g G , 5 / 8 l o n g adermal. 2 0 G . 2 2 G . 2 5 G . 2 6 G illin can be administeredn j e c t i o n o r a n IV s o l u t i o n r a n i n t r a d e r m a l i n j e c t i o n adermal or subcutaneous injectionr a s u b c u t a n e o u s i n j e c t i o n s gr 10 of aspirin for a. 0 . 6 m g . 1 0 m g . 6 0 m g . 6 0 0 m g .5

g t t / m i n u t e g t t / m i n u t e g t t / m i n u t e g t t / m i n u t e orm o g l o b i n u r i a . C h e s t p a i n . U r t i c a r i a s t e n d e d n e c k v e i n s ollowing conditions may. F e v e r e n a l F a i l u r e e h y d r a t i o n mon signs andin or discomfort at the IV insertion sitea and warmth at the IV insertion sitet r e a k e x i t i n g t h e IV i n s e r t i o n s i t e a n k b l e e d i n g a t t h e i n s e r t i o n s i t e mining whether a patienthe patient if he/she has used ear drops before e the patient repeat the nurses instructionsonstrate the procedure to the patient and the patient to demonstrate the procedureof medications cany o r a l m e d i c a t i o n s sules whole contents are dissolve in waterric-coated tablets that are thoroughly dissolved tablets designed for oral use, except fores after receiving an. T o l e r a n c e i o s y n c r a s y . S y n e r g i s m . A l l e r g y oom after femoral. All of the following are appropriateess femoral, popliteal, and pedal pulses every 15 k the pressure dressing for sanguineousess a vital signs every 15 minutes for 2 hou rsr a hemoglobin and hematocrit count 1 hourough:rotective response to clear the respiratoryr i m a r i l y a v o l u n t a r y a c t i o n duced by the administration of an antitussive be inhibited by splinting the abdomen as chills and beginsp l y i c e d alcohol spongesvide increased cool liquids vide additional bedclothesvide i n c r e a s e d v e n t i l a t i o n ialist is a nurse whocertified by the National League foreived credentials from the Philippinea d u a t e d f r o m a n a s s o c i a t e d e g r e e m p l e t e d a m a s t e r s d e g r e e i n t h e reasing urine acidityc r e a s e b u r n i n g s e n s a t i o n s a n g e t h e u r i n e s c o l o r a n g e t h e u r i n e s c o n c e n t r a t i o n ibit the growth of microorganismsd stools indicate:p e r G I b l e e d i n g p e n d i n g c o n s t i p a t i o n e f f e c t o f m e d i c a t i o n l e o b s t r u c t i o n ing processAssessment. A n a l y s i s PlanningEvaluationurces of i t e p o t a t o e s . C a r r o t s . A p r i c o t s . E g g y o l k s y nursingtain the drainage tubing and collection bagate the patient with 1% Neosporin solution p the catheter for 1 hour every 4 hours totain the drainage tubing and collection bagt is used to:en blood donors for antibodies to humanncy virus (HIV)est blood to be used for transfusion for HIVi n d i a g n o s i n g a p a t i e n t w i t h A ID S l o f t h e a b o v e els most commonly used forb c l a v i a n a n d j u g u l a r v e i n s a c h i a l a n d s u b c l a v i a n v e i n s m o r a l a n d s u b c l a v i a n v e i n s a c h i a l a n d f e m o r a l v e i n s tion before a surgicalving the site on the day before surgeryying a topical antiseptic to the skin on theing the patient take a tub bath on the morninging the patient shower with an antiseptic soap ,d o m i n a l m u s c l e s . B a c k m u s c l e s . L e g m u s c l e s p e r a r m m u s c l e s ally develops ineases partial thromboplastin timeu t e p u l s u s p a r a d o x u s mpaired or traumatized blood vessel wallnic Obstructive Pulmonary Diseaseimmobilized patient, lungpiratory acidosis, ateclectasis, andeustic breathing, atypical pneumoniae yn e - S t r o k e s r e s p i r a t i o n s a n d ssmails respirations and hypoventilation bladder elimination,eased urine acidity and relaxation of theee retention, bladder distention, andesis, natriuresis, and decreased urineeased calcium and phosphate levels in ,. Wearing gloves is not. This is done by blood typing (a.,ay and thus should. Because of the. Signs and symptoms of phlebitisn site, and a red, asiction may cause skin to feel cold to, such as medical surgical nursing. These. Irrigating the bladder with, not the day before. A topicalub bathing might transfer organisms to, and injury to a. Arterial blood disorders (such as pulsus.